<p>Progress toward racial health equity cannot be made if we cannot measure its fundamental driver – structural racism. As in other epidemiological studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and grey literature published during 2019-2021 to accompany the work of Groos et al. (J Health Dispar Res Pract. 2018;11(2):Article 13), which surveys the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism, using residential segregation as well as other segregation-driven measures as proxies of structural racism, measuring structural racism as spatial exposures, an increasing call by epidemiologists and other health researchers to measure structural racism as a multidimensional, multi-level determinant of health and related innovations, the development of policy databases, the utility of simulated counterfactual approaches in the understanding of how structural racism drive racial health inequities, and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several future steps to improve the science around structural racism measurements, which is the key to advancing antiracism policies.</p>

Background and Objectives: Long-term services and supports in the U.S. are increasingly

The purpose of this study was to develop a deep understanding of the lived experiences of structural racism and discrimination among older Black Americans’ and their perceptions of structural racism across their lives. We also considered individual and community resilience capacity and response in the face of systemic racism. In-depth interviews were conducted with Black community–dwelling adults aged 55 and older in and around Baltimore City. The interview guide used nine contexts to explore perceptions and experiences with structural racism over the life course. Two researchers used reflexive thematic analysis to code and analyze the data. Participants endorsed structural racism to varying degrees across contexts of education, employment, neighborhood, healthcare, and income/wealth. Participants who denied structural racism placed blame for Black underachievement on factors such as personal and community deficiencies, unsafe neighborhoods, and institutional indifference. There was broad agreement about the existence of structural racism within the domains of policing and violence but participants were largely ambivalent about other domains such as environment, media, and civics. Resilience factors that helped individuals to resist and rebound from racism emerged as an unexpected and important theme. We used Public Health Critical Race Praxis and the Cells to Society frameworks to contextualize these findings. Due to the ubiquitous nature of racism, individuals may not fully appreciate the impact of structural racism and its impact on Black well-being. This ordinariness of racism is harmful but may simultaneously contribute to resilience within Baltimore’s Black community.

have no potential conflicts of interest to declare. Dr. Vincent Mor is a paid consultant to NaviHealth, Inc. and chair their Scientific Advisory Board. NaviHealth is an independent entity within OPTUM. The company offers post-acute care (PAC) management and services to more than 1.5 million beneficiaries in all regions of the country through its partnerships with health plans and health systems.

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated. Context: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. Methods: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest–posttest design. Findings: After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. Conclusions: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Racial and ethnic health inequities are driven by multiple social and political factors. Race-neutral policies that overlook the role of racism in policy and in disparities may also contribute to inequities. In response, one broad policy-making approach has been to craft race-based policies that attempt to improve outcomes explicitly for specific racial groups. However, race-based policies can be politically infeasible. We propose a racism-conscious approach to policy making and health care practices that addresses racism and advances health equity. Using postacute and long-term care policies as a backdrop, we identify five key steps to creating racism-conscious policies that rest on continuous community engagement and policy evaluation. The proposed racism-conscious framework can be used to develop a new health policy or to redesign an existing policy, and it can work for federal, state, local, and organizational policies, practices, or both.

Nursing homes (NH) and other institutional-based long-term care settings are not considered an appropriate place for the care of those with serious mental illness, absent other medical conditions or functional impairment that warrants skilled care. Despite policy and regulatory efforts intended to curb the unnecessary placement of people with serious mental illness (SMI) in these settings, the number of adults with SMI who receive care in NHs has continued to rise. Through a scoping review, we sought to summarize the available literature describing NH care for adults with SMI from 2000 to 2020. We found that SMI was operationalized and measured using a variety of methods and diagnoses. Most articles focused on a national sample, with the main unit of analysis being at the NH resident-level and based on analysis of secondary data sets. Understanding current evidence about the use of NHs by older adults with SMI is important to policy and practice, especially as we continue to grapple as a nation with how to provide quality care for older adults with SMI.