Aging has always been part of the human condition. And as we age, sometimes we require more care than our loved ones can provide. If your family member needed extra care—whether at home, a nursing home, or an assisted living facility—you’d want it to be top notch, right?

That’s the level of care all seniors deserve, according to Shekinah Fashaw-Walters and Tetyana Shippee.

Fashaw-Walters is an assistant professor and Shippee is a professor in the School of Public Health’s Division of Health Policy and Management. Both are researching racial and ethnic disparities in care for older adults.

As the U.S. is becoming more racially and ethnically diverse, Minnesota—still a majority-white state—generally gets high marks for care of older adults. But a closer look shows that often doesn’t extend equally to older adults who are Black, American Indian, or low income. “And that gap has been increasing over time,” Shippee says. While much of her research has focused on nursing home care, she says “we need to expand our collection of race and ethnicity data for other types of services, because if you don’t measure something, you can’t improve it.”

Gauging disparities
Shippee came to the U of M in 2010 and helped recruit Fashaw-Walters in 2021. Much of Shippee’s work focuses on measuring and improving quality of life in nursing homes and, more recently, assisted living facilities. As a social gerontologist—who studies social rather than biological aspects of aging—she looks at “person-reported” satisfaction of residents in long-term care settings. Fashaw-Walters primarily studies clinical outcomes of care in both nursing homes and, increasingly, in home health agencies.

Fashaw-Walters articulates her goals on her website: “[A] society where the strength, autonomy, dignity, and independence of all older adults are enhanced by policies and practices that promote healthy and equitable aging.”

To make that happen, both are developing tools to gauge disparities in older adult care between different populations. This fall Fashaw-Walters secured an exploratory grant from the National Institutes of Health to continue her efforts in creating measures of equity in home health care.

“We’re looking at [whether] folks from minoritized backgrounds are doing the same as, worse than, or better than their white counterparts using the same types of home health agencies,” she explains. “We’re creating ‘health equity star ratings’ very similar to the quality of patient care star ratings that currently exist [for home health agencies].” That tool will include measures such as rate of hospital readmissions and changes in some activities of daily living, such as bathing and walking.

Regulatory differences—in federal vs. state policies, between one state and another, and for different types of care—are part of the challenge. That’s particularly true in the realm of home health and community-based care.

“When you see one state’s home and community-based-service policy approach ... you’ve seen one state,” Fashaw-Walters says. “It’s very different from state to state, which makes it more difficult to look at.”

Fashaw-Walters cites research showing that 89 percent of older adults prefer living at home and Medicare currently spends $18 billion per year on home health care. “And compared to other Medicare beneficiaries, home health users are poorer, sicker, and more likely to identify as Black,” she says.

A ’racism-conscious’ approach
Fashaw-Walters also developed a new framework, published in Health Affairs in early October, which is a “racism-conscious approach” to policymaking and health care practices. She says a “colorblind” approach has yielded unintended consequences—worse outcomes for Black, brown, and Indigenous patients. The proposal identifies five steps, from examining inequities to designing specific new policies, designed to move toward closing those disparities.

Shippee, meanwhile, is part of the Moving Forward Coalition, a national task force convened to implement recommendations of a report on nursing home quality by the National Academies of Science, Engineering, and Medicine. She chairs a committee on improving quality of life and person-centered care for nursing home residents. “We’re [seeking] to improve collection and implementation of residents’ goals, priorities, and preferences,” she says.

Shippee is also excited about a new Minnesota report card—mandated by the state legislature in 2019 and launched this fall—on assisted living facilities. The report card will include measures of resident quality of life and family satisfaction. (A statewide survey showed that stakeholders identified quality of life and satisfaction for residents and family members as the most important measures.)

“Think about what makes us who we are: the kind of food we eat, and the things we like to do,” Shippee says. Often the food served in nursing homes is not relatable to people from different cultures and traditions, and activities offered aren’t culturally relevant. No such tool currently exists to measure those things, Shippee says, and the survey will give consumers reliable data to compare facilities. “Facility-designed and -collected satisfaction surveys are not as credible, because residents are afraid of saying bad things,” she explains. “They don’t know who will be seeing it.”

Driven by respect and admiration
Respect for elders informs both researchers’ work. While she was in high school, Fashaw-Walters cared for one her grandmothers, including bringing her to dialysis appointments. “And my other grandparents, I had a really rich relationship with them as well,” she recalls. “That really created this fire to start thinking about how we create better care experiences for older adults. ... I started to make more connections between historic injustices and what I felt like older adults should be experiencing.”

Shippee came to gerontology after she interviewed a retired faculty member for an undergraduate sociology class assignment at the Tennessee university where she was studying. He was caring for a spouse with dementia. Shippee befriended them both and ended up moving in with them.

“That changed my course of interest. It was the strength of this couple that really inspired me.” She also spent two years, from 2003 to 2005, living alongside older adults in a nursing home. “Experiential learning has been a really big part of my work,” she says.

“One way to [reckon with] ageism—all ‘isms’—is, how do you experience it at least a little bit?” Shippee says. “Living there, [I experienced] staff walking in the room without knocking. Once I had dinner with someone and they died that night; I was the last person who saw them.”

Through daily living, she learned about “these traumas that older people go through that are often invisible to others.”

She also made dear friends. When Shippee got married in Minnesota in 2005, a bus filled with residents, driven by the administrator of that Indiana nursing home, came to celebrate with her.

Actionable research for equitable care
Fashaw-Walters says that “Inequities, especially racial inequities, are tied to structural racism. We can change the structural pieces; we can change the policies that exist. There are different approaches we can take to lowering the barriers that create so many of the inequities we see.”

For example, tying reimbursement to equity measures could make a big difference, Fashaw-Walters says. 

“Once we’re reimbursing based on equity, we’ll start to see the outcomes that we really want to see. I’m hopeful that ... we’ll start to see autonomy and dignity returned to a population that I feel has lost a lot throughout the years.”

Shippee thinks ensuring adequate staffing levels, offering scholarships for staff who want to develop culturally relevant programming, and paying staff living wages would also help address issues. A survey of 1,450 Minnesota nursing home workers, released by the Service Employees International Union in October, showed that two-thirds struggle to meet basic living expenses.

Despite the challenges ahead as the “silver tsunami” of aging adults swells—Fashaw-Walters is optimistic. “Folks who have historically gone through so much, from witnessing lynchings to Jim Crow segregation ... they’ve had to fight for their dignity and autonomy, despite structures and policies that were put in place to take it away,” she says. “To allow my work to support that fight for a population that deserves it? I’m really hopeful for that.”

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