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Poor, Black People Have Worse Home Health Care Outcomes

An article came across my desk last week suggesting that Poor and Racial Minorities have Worse Home Health Care Outcomes.  If this surprises you, please stop reading and surrender your nursing license now.

If you read further, the article clarifies the Racial Minorities as Black even though the OASIS data set collects information on American Indians, Alaska Natives, Asians, Hispanic and Latinos, Native Hawaiian or Pacific Islanders as well as white patients.  So essentially, what the article is stating that if you are Black or poor, your health outcomes are worse.

Nurses know that African Americans are predisposed to certain diseases and conditions.  Hypertension and diabetes come to mind immediately. Nearly 42% of Black men and more than 45% of Black women aged 20 and older have high blood pressure.

It is the sequelae of those illnesses that disproportionately affect the black community.  This is where economics comes in and skews the healthcare received by Black people to an unacceptable degree.  Specifically, consider the following statistics:

  • Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
  • Strokes kill 4 times more 35 to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites
  • Cancer treatment is equally successful for all races. Yet Black men have a 40% higher cancer death rate than white men. Black women have a 20% higher cancer death rate than white women.


  • Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.  See last week’s blog post.

This information is obtained from an article on WebMD

There are so many reasons for these disparities that the study is almost useless to the home health industry.   So maybe the answer is to do what we always done – assess the individual needs of our patients and plan care accordingly.  But sometimes in our effort to be ‘color blind’ factors are overlooked that are closely correlated with being Black and poor in the USA.

About 24 percent of Black people cannot read past a basic level compared to 14 percent White people.  This information is not part of the OASIS dataset and probably shouldn’t be because the time and skills to assess reading ability are not available to us.  There are ways around illiteracy as most nurses know but they take time.  Take your time and be creative.  Send us an account of how your teach patients who cannot read.

Patients younger than 62 who are referred to you may have Medicaid as a primary payor.  In some states, Medicaid provides second rate health care encouraging the use of Emergency Room services when the patient is unable to wait for an appointment set in the distant future.  Medicaid approvals for some medications take time.  We can’t do anything about how the Medicaid system works but we can help the patients navigate the maze.  The truth is that we should be able to treat patients the same regardless of payor source but that ship sailed a long time ago.  If you want to be effective, you must know how the Medicaid system in your state functions.

Poverty and crime have an enduring relationship that isn’t likely to end soon.  Even though you are Wonderwomen and Supermen, you are not able to flash your badge and arrest the bad guys.  Consider the constant stress of living in a home where violent crime is common and how that might affect a patient.  When family members are addicts, patient medications may be diverted leaving a patient in pain unless they want to report a loved one to the police.  I have seen doors with multiple locks leaving me to wonder if there is an escape route in the event of a fire.

In rural areas, crime may not be a problem but the expense of getting to a physician’s office may be out of reach.   Family members may be willing to drive the patient but if they work, they might lose an entire day’s wages.  In these cases, it is possible that truly diligent assessments along with detailed reports to the physician may occasionally eliminate the need for an office visit.

Cheap food is frequently not on cardiac or diabetic diets.  Plus it adds body weight complicating pretty much every disease or condition.  The fact is that poor people eat cheap food and patients who cannot read are unable to follow that food list you gave them, anyway.

As much as we would like to, we cannot teach the world to read, fix Medicaid or reduce crime.  Driving patients to the physician’s office is impractical and basically a bad idea for reasons that would fill another blog post.  You can’t even plant a garden in their backyard to provide vegetables.

We have to look for allies.  Every agency should have a list of community services that can assist us in improving our patient’s’ chances of becoming a little more independent.   It should be reviewed regularly and distributed to all nurses.  Meals on Wheels isn’t the only service available.

We also need to realize that while outcomes are important, there are some things we cannot control.  When someone has untreated hypertension resulting in a stroke prior to admission, it is unreasonable to expect the same good outcomes that result when a patient is referred after being diagnosed with hypertension before a stroke occurs.   That doesn’t mean that we shouldn’t try our best.

The bitter pill to swallow is that our best may not be good enough.  But, it could be better.   Your personal best may be to spend an extra ten minutes with a patient so your functionally illiterate patient can understand the education you provided.  An agency may adopt a policy where breaking even financially on poor and Black patients is acceptable and schedule a few more visits.  Case managers could supplement visits with regular phone calls.  Safety for nurses and patients may be enhanced by an inservice from local law enforcement.

The value of a life is constant throughout races and economic status.  As Malcomb Forbes once said, “You can easily judge the character of a man by how he treats those who can do nothing for him.”  But you may be surprised.  The people who appear to be able to do nothing for you often do the most.

NOTE:  This is an article about African Americans.  I have used the term ‘Black’ because that is what was found in the literature and it is easier to type.  No disrespect is intended.
7 Comments Post a comment
  1. Courtney Roy Clofer RN #

    Great article and so true. Our agency has committed to serving the usually under served.Our home health compare and STAR ratings take a beating but we are trying to make a difference if nothing else.

    October 17, 2017

    • There is nothing more important than making a difference. Look for some other referral sources who may be able to dilute the poor black you care for but always strive to make a difference first. Hopefully Star ratings will be adjusted in the future. Until then, sleep well.

      October 17, 2017
  2. Nicole White, RN #

    One of the first steps is to assess literacy as much as we can. People are often embarrassed that they can’t read and have an impressive set of adaptive behaviors to try to hide it from us. I can’t provide the best teaching until I know if they can read.

    I know we’re not trained to assess reading ability thoroughly and perfectly, but one trick I’ve found is to hand the patient a sheet of paper with some possible “Patient Goals” listed on it. I make the type about the size of that on a medication bottle. I ask them to read through the list and choose one or two goals that are most important to them.

    Now I’ve: truly assessed vision (for my OASIS), assessed the patient’s ability to read at that level, AND I’ve got myself a couple of truly patient centered goals, and we can use those as a starting point to creating the care plan with ACTUAL patient involvement.

    If they can’t complete the task, I know I need to delve deeper either on the eyesight (“Do you wear reading glasses? Can I help you find them?”) or the literacy (“Do you find it easier to understand information when you hear it or see pictures?”) or both.

    October 17, 2017

    • That is great! It is the most creative way I’ve heard in a long time to enhance the quality of an assessment. And you include patient goals. Your Super Powers inspire me.

      October 17, 2017
    • sahily #

      This is such a great idea!!

      February 12, 2018
  3. Kyandra #

    There are very simple 1 question health literacy screens out there, that while they are not perfect, they are a start. I have lobbied more than one EHR to put them on their OASIS and failed. If more asked for them, we’d know a lot more, but never enough


    October 20, 2017

    • I did not know about ‘Health Literacy Screens’ but will google them and post some on this site. I guess the term was foreign to me. Thanks for the info. As a group, home health nurses are amazingly creative and could come up with patient specific visual tools or even auditory tools. But it is a sensitive issue to assess.

      I look for books and magazines in the home and handwritten notes. Many people who read nothing else will keep a bible in reach. It isn’t a fail safe way to assess literacy but it is a start. Calendars require a certain level of literacy to maintain but not necessarily a level that understands health information.

      Twenty years from now, home health care nurses will be looking for iPads and eBook readers. Could be an adventure!

      October 20, 2017

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