Racial and Ethnic Differences in Access to Alzheimer Special Care Units After Hospitalization

Importance: Older adults with dementia often need nursing home care after hospitalization. Objective: To examine whether Black and Hispanic patients have different access to Alzheimer disease special care units (ASCUs) after hospital discharge compared with White patients. Design, Setting, and Participants: This was a retrospective cohort study of 100% Medicare fee-for-service claims from January 2018 to February 2020. Participants were Medicare beneficiaries with a prior diagnosis of dementia who were hospitalized or admitted to nursing homes from January 2018 to August 2019. Data analyses were performed from January to July 2026. Exposure: The race and ethnicity of a patient. Main Outcomes and Measures: The primary outcome was long-term care admission to a nursing home with an ASCU. An unadjusted logistic regression, an unadjusted 2-level (patient-hospital) model, and a multivariable 2-level model were conducted to assess racial and ethnic differences in long-term care admission to a facility with an ASCU and whether patient and hospital characteristics could explain the differences. Results: Of the 1 428 849 patients, 130 125 (9.11%) were Black, 77 868 (5.45%) were Hispanic, 1 164 829 (81.52%) were non-Hispanic White, 56 027 (3.92%) were of other races (American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander), 839 328 (58.74%) were female, and 1 075 171 (75.25%) were aged 75 years or older. A total of 122 654 patients (8.58%) became long-term care residents within 6 months of hospital discharge, and 19 313 patients (1.35%) were admitted to facilities with an ASCU. In the unadjusted logistic model, Black (relative risk [RR], 0.69; 95% CI, 0.65-0.73) and Hispanic (RR, 0.48; 95% CI, 0.44-0.53) patients had lower probabilities of long-term care admission in a facility with ASCU than White patients. After controlling for the clustering of patients in a hospital, the RR substantially increased to 0.94 (95% CI, 0.88-0.99) for Black patients and 0.78 (95% CI, 0.71-0.85) for Hispanic patients. Further controlling for patient and hospital characteristics slightly reduced these RRs. Disparities for Black patients (RR, 0.89; 95% CI, 0.84-0.95), but not Hispanic patients (RR, 0.93; 95% CI, 0.84-1.02), were also observed in the subcohort of Medicare beneficiaries who became long-term care residents. Conclusions and Relevance: The findings of this cohort study suggest that disparities in access to specialized dementia care occur mostly because patients from minoritized racial and ethnic groups are treated at hospitals with low rates of discharge to ASCUs. Efforts to improve dementia care access should focus on enhancing hospital discharge planning and addressing the extra barriers faced by female patients.