Racial differences in skilled nursing care and home health use: the mediating effects of family structure and social class

OBJECTIVES: This study investigates whether utilization of skilled nursing facility (SNF) care and Medicare home health differ by race. It then seeks to understand the extent to which family structure and social class explain any differences observed. METHODS: Linking measures from the 1989 National Long-Term Care Survey with Medicare claims data, we model SNF care and home health use as competing risks using a Cox proportional hazards model. Age at first use is the outcome measure, consistent with the analysis of long-term care use as a life-course transition. RESULTS: Blacks postpone both home health and SNF care until later ages than Whites, and both children and grandchildren play a part in deferring their use until even later ages. When formal assistance is needed, Blacks are more apt than Whites to use home health over SNF care. The race difference in SNF use is even greater than that previously reported for all types of nursing home use combined. Social class has little influence on the risk differential. DISCUSSION: Contrary to expectations, Black elders are not counterbalancing their lower rate of SNF use with a higher rate of home health use. This suggests that there are differences in need, preference, or access that are yet to be identified. Future research should consider the relationship between family structure and informal caregiving, variation in physician referral patterns by race, and the availability of long-term care in traditionally African American communities.