The Use of Social Deprivation Index to Examine Nursing Home Quality

Abstract

Health and health care access inequities vary along social and economic gradients. The Social Deprivation Index, is a composite measure of socio-economic factors (schooling, living conditions, transportation, home ownership, marital status). Using this index, we can explore how nursing home performance can be influenced by the resources available in the environment. The purpose of this paper is to explore the relationship of social deprivation and quality of care. Secondary data for 2011-2014 from Brown University’s Long-Term Care Focus, CASPER (Certification and Survey Provider Enhanced Reporting), and the Census American Community Survey was used. Structural equation modeling with maximum likelihood estimation was used to examine the total, direct, and indirect effects of the variables as conceptualized using Donabedian’s structure, process, and outcomes framework. In this study, structure consisted of RN staffing mix and RN, LPN, and CNA staff intensity; process was conceptualized as anti-psychotic medications, and outcomes as re-hospitalizations, falls, and pressure ulcers. Control variables included organizational level (total beds, percentage of Medicare and Medicaid, occupancy, percentage of minorities, multi-facility and for-profit status) and market level (Hirschman Herfinadahl Index for competition). We found as the munificence of the environment decreases, organizations will substitute out highly compensated and trained RNs and increase the staffing levels of LPNs and/or CNAs. All nurses, regardless of skill mix, are associated with decreased use of anti-psychotic medications; however, RNs have the greatest impact. Higher uses of anti-psychotic medication is associated with greater prevalence of re-hospitalizations, falls and pressure ulcers. This study illustrated that organizations are responsive to the resources available in their environment. All levels of nurse staffing can have a positive impact on improving processes, like decreasing the use of anti-psychotic medications. Nursing homes located in socially deprived areas may lack the staff mix to reduce the use of anti-psychotic medications, which in turn, has a detrimental effect on resident quality of care outcomes.