Papers of the Applied Geography Conferences (2008) 31: 273-282

READY OR NOT? NURSING HOMES FOR BABY BOOMERS:

A CASE STUDY OF CLEVELAND, OHIO

Rebecca Lee
Department of Integrated Life Sciences
Kent State University
Kent, OH 44242-0001

1. INTRODUCTION

The population of persons sixty-five years and older in 2000 was roughly about 35
million, or 12.4 percent of the total population in the United States (Rice & Fineman, 2004).
This number is expected to increase dramatically in the near future because of the 76 million
persons that currently are between 55 and 64 years old, also known as the baby boomer
generation. The baby boomer generation includes those born between 1946 and 1964. By
2050, the number of elderly, those 65 years and older, is expected to number around 80 million
people in the U.S. (Schneider, 1999; Knickman and Snell, 2002). The frail elderly, or those 85
and older, will be the fastest growing age group of the U.S. population. This increase of senior
population will definitely have a profound impact on many aspects of society, especially in the
healthcare system.
Among the many senior population needs, the availability of nursing homes will
likely affect the quality of seniors’ lives and those who care for them. The need for long-term
support services tends to increase with age (Bishop, 2004). With such an increase in the
population who will most likely need long-term support services, there will be an increase in
nursing home demand. Ness et al. (2004) suggested that 42 percent of the U.S. population 70
years and older will spend time in a nursing home in their lifetime. The number of elderly
living in such residences will increase dramatically over the next few decades. According to
Zedlewski and McBride (1992), the need for nursing homes will nearly triple even though the
elderly population will only increase by 125 percent by 2010. The number of elderly who need
nursing homes is expected to increase from 1.8 million to 3.4 million in 2010, and to 5.3
million in 2030 (Mulvey and Stucki, 1998). This increase could be attributed to the increase in
the proportion of the elderly who are very old, unmarried, and disabled which, in turn, suggests
that needs for nursing homes will only be on the rise. Consequently, the problem of whether the
existing spatial organization and capacity of nursing homes can meet the expected increasing
needs becomes a critical issue.
In this paper, I discuss a practical approach to evaluating the demands for and the
capacity of nursing homes with respect to the increasing senior population. Location-allocation
models are especially suitable for planning the spatial organization of facility networks.
Algorithms developed from these models are generally designed for selecting sites for facilities
that provide services to a geographically dispersed population or pattern of demand. Locations
of facilities are selected and evaluated based on a set of pre-defined objectives and under a set
of constraints. At the same time, demands can be allocated to service facilities according to the
objectives and constraints. Ghosh and Harche (1993) suggested three reasons for the popularity
of location-allocation models: (1) they are capable of determining the optimal locations of
multiple facilities simultaneously; (2) they can be applied in siting facilities with a wide variety
of objective functions that can be mathematically formulated to fit specific modeling
environments; and (3) they may find optimal solutions by using heuristic algorithms to allow
alternative models be generated for further evaluation by policy makers.
With increasing computational speed and decreasing costs of computational memory
(and storage), GIS approaches are taking location-allocation models to a new level (see, e.g.,
Yeh and Chow, 1996). This allows analysts to work with larger, more realistic data sets than

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before and to conduct iterative simulations that once were too labor-intensive, too time-
consuming. For example, Kumar (2004) used location-allocation modeling to evaluate the
changing geographic access to, and locational efficiency of, health services in two Indian
districts. Harper et al. (2005) developed a discrete-event geographic location-allocation
simulation model for evaluating various options for the provision of services with near real-life
scenarios.
This study is an example for demonstrating how location-allocation models can be
used to assess the potential demands for nursing homes and how the current spatial
organization of nursing homes matches the geographic distribution of the senior population.
Nursing homes are different from retirement homes in many respects. In Cuyahoga County,
Ohio, it seems that the majority of existing nursing homes house seniors who need high levels
of medical attention and who need continuous help in daily routines. While studies of senior
populations and their health care facilities can include both nursing homes and retirement
homes, this paper focuses specifically on nursing homes to address whether existing facilities
would be able to accommodate seniors as they become more frail.

2. METHODS

Data were downloaded from the U.S. Bureau of the Census (2000). For the purpose
of this study, the population of the 50-64 years age group (or 50/64 group) was chosen. This
group represents the future senior population. The data of population counts were merged with
GIS boundary data of census tracts in Cuyahoga County, Ohio, from ESRI. This gave a
polygon data layer of census tracts with attributes of population count.
For this study, nursing home data were acquired from UCompareHealthCare (2007).
In addition to the names and addresses of the nursing homes in Cuyahoga County, Ohio, the
website also provided information regarding a number of attributes, including number of beds
and occupancy rates. To determine the locations of nursing homes, GoogleEarth was used to
geocode addresses into latitude/longitude coordinates. The coordinates were then converted to
create a point data layer of nursing homes and their attributes.
Descriptive and correlation statistics were used to compare how population counts
and nursing home attributes were distributed and related. In addition, maps and spatial
autocorrelation coefficients were used to explore if population and nursing home capacity have
any spatial clusters. Maps were generated using ArcGIS 9.2. Spatial autocorrelation
coefficients were calculated using computer codes available in lee and Wong (2001). For
spatial autocorrelation, Moran’s Index, I, as described in Lee and Wong (2001, 156-164) was
used to measure spatial clusterness of a distribution.
In the case of this study, nursing homes were treated as service centers and the
locations of the senior population as demand locations. I assumed that existing nursing homes
will continue to operate and that no new nursing homes are to be added before the current
50/64 group grows old enough to require their services. For the assessment of locations of
nursing homes with respect to the distribution of senior population, two criteria in carrying out
location-allocation analysis were applied: the minimum distance and maximum coverage
criteria.
The minimum distance criterion’s objective function is to minimize the total
weighted distances from all geographic units to all centers. Specific discussion of the
minimum distance and the maximum coverage criteria can be found in Hakimi (1965), ReVelle
and Swain (1970), and ReVelle (1991).
The senior populations (demands) were allocated to nursing homes according to the
minimum distance criterion. In other words, this criterion assigned a senior population to its
nearest nursing home. With the maximum coverage criterion, the objective of the analysis is to
maximize the inclusion of demands for each center within a specified distance. This gave each
nursing home all senior persons within a pre-set distance from its location. In this study, the
pre-set distance was set at 10 miles to ensure that the entire county was covered. Both criteria
have been implemented and made available in ArcInfo Workstation 9.2 (ESRI, 2007). In this
study, a total of 104 nursing homes and 502 census tracts with population counts were used.

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 3. RESULTS AND ANALYSIS

3.1 THE SENIOR POPULATION

The distribution of the senior population densities in Cuyahoga County, Ohio, is very
different from that of the overall population in the county. The 50/64 group distributes evenly
among census tracts. This suggests that a more spatially disperse distribution of nursing home
locations may better meet the need of the 50/64 group, which is the future senior population.
The 50/64 group distributes around the city center with gradually decreasing densities
towards the suburbs (Figure 1). The map suggests this group scatters into the suburbs. The
compact distribution of the current senior population (those 65 years and older) may have been
to take advantage of the various services offered by the city and the availability of public
transportation system. For a base-line comparison, the distribution of the current senior
population (age 64 and above) is also listed.
The distribution of senior population in the county seems to have clear local clusters.
They display local clustering more than the overall population. Census tracts near the city
center and census tracts in the suburbs are expected to have more senior population in the
future, when the current 50/64 group becomes part of the senior population.

3.2 NURSING HOMES

There are 104 nursing homes in Cuyahoga County (UCHC, 2007). Their capacities
range from 8 beds to 320 beds, with 38 to 100 percent occupancy rates. Among the nursing
homes, most of them have over 100 beds with a median of 113.5 beds and an average of 87.6
percent occupancy rate, accommodating an average of 102.7 residents.
The 104 nursing homes in the county have different ownership structures and offer
different types of services. However, none of the attributes was found to be correlated to the
capacity of the nursing home, except for those nursing homes belonging to franchises tend to
have more beds than independently operated nursing homes. For analytical simplicity, nursing
homes were classified into three categories: those having less than 50 beds, those having 50 to
100 beds, and those having more than 100 beds.
The distribution of nursing homes does seem to cover the entire county well, but it is
apparent that nursing homes tend to cluster locally. As shown in Figure 2, nursing homes are
in locations of small clusters over the entire county, with lower densities in the east and
southeast. The lack of overall concentration might be due to meeting scattered demands around
the county.
When plotting occupancy rates of nursing homes in Cuyahoga County, the pattern
clearly shows that occupancy rates do not follow where current senior population resides. For
example, the nursing homes in and around the center city have good occupancy rates but most
census tracts in that area have few senior persons residing in them. Alternatively, several
nursing homes with lower occupancy rates are located in census tracts with ample senior
population. Figure 3 shows this pattern with circles of different gray tones denoting nursing
homes of different occupancy rates against a backdrop of how the current senior population
distributes. This suggests that senior population may have included more factors, besides just
choosing the nearest nursing home, when they made their selections.

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 FIGURE 1
SPATIAL DISTRIBUTION OF POPULATION DENSITY PER SQUARE MILE
BY CENSUS TRACTS, 2000

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 FIGURE 2
SPATIAL DISTRIBUTION OF NURSING HOMES, CUYAHOGA COUNTY, OHIO

FIGURE 3
NURSING HOME OCCUPANCY RATES AND SENIOR POPULATION,
CUYAHOGA COUNTY, OHIO

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3.3 LOCATION-ALLOCATION ANALYSIS
As discussed earlier in the methods section, two criteria were used to study the
demand and capacity of the nursing homes in Cuyahoga County, Ohio. The first criterion, the
minimum distance criterion, allowed for consideration of the interplays between nursing homes
and senior population to see if any census tract has seniors needing to travel excessively long
distances to the nearest nursing home. The implication is that if long distances were necessary
with the current spatial configuration of nursing homes, new nursing homes may be needed to
reduce such distances. Alternatively, the second criterion provided the information that, if any
nursing home was found to be assigned excessively large amounts of demands, then there may
be a need to expand the capacity of existing nursing homes or to add new nursing homes in
those locations. In either case, the allocation analysis should provide a feasible way to assess
how the spatial configuration and capacity of current nursing homes are serving the present
senior population and will serve the future senior population. For computational simplicity, I
lumped the capacities of nursing homes together if they are located in the same census tract. I
chose a distance of 10 miles for the maximum coverage criterion as it is slightly longer than
the distance between farthest neighboring nursing homes.
In Table 1, weighted average distances are listed for two criteria. As expected, shorter
weighted average distances are observed when there were more nursing homes included in the
analysis. Between the two criteria used, it can be seen that the weighted average distances
converge faster under the minimum distance criterion than under the maximum coverage
criterion.

TABLE 1
AVERAGE DISTANCE TO NEAREST NURSING HOME
Number of Nursing Homes Minimum Distance Maximum Coverage
in Analysis
1 7.95 5.99
25 1.53 2.12
50 1.19 1.27
75 1.10 1.10
All 1.09 1.09

When there were more than 65 nursing homes included in the analysis, there was
very little improvement in reducing the average distance by adding additional nursing homes
(Figure 4). The trend of decreasing average distances from census tracts to nursing homes is the
most dramatic when there are only 20 or less nursing homes. Beyond that level of nursing
homes, the reduction in average distance by adding more nursing homes becomes minimal.
When there are 65 or more nursing homes in the county, there is hardly any reduction in these
average distances.
Figure 5 displays maps that show how the census tracts were assigned to the selected
nursing homes under the minimum distance criterion for the two age groups. The 20 or 65
nursing homes mapped in Figure 5 were both selected by the location-allocation procedures
under the minimum distance criterion. Again, for base-line comparison, similar maps for the
senior population (age 65 and above) are also included for reference.
Notice that, given the same configuration of nursing homes with their locations and
capacities, the two age groups are not served equally. It seems that the 55-64 age group lives
more along the suburban areas as opposed to the older age group. Consequently, more nursing
homes may be needed for locations along the peripheral areas of the county.

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 FIGURE 4
WEIGHTED AVERAGE DISTANCE AND NUMBER OF NURSING HOMES,
AGE 50-64, CENSUS TRACTS, 2000

FIGURE 5
SPATIAL CONFIGURATION OF CENSUS TRACTS WITH RESPECT TO NURSING
HOMES

One of the advantages of applying location-allocation models to geographic supply-

demand problems is that the method is capable of assessing where excessive or insufficient
capacity may occur. In this study, the allocation process assigned senior population to

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individual nursing homes according to the minimum distance and the maximum coverage
criteria. The senior population in the census tracts were all summed up and assigned to the
same nursing home as the estimated demand for the nursing home. This summation created an
estimated demand for each nursing home. Together, the process established the distribution of
demands for nursing homes by the population of the age group used. This distribution was
derived according to the geographic patterns of that age group. Finally, the estimated demands
were normalized by the actual number of bends in each nursing home to derive the demand-to-
capacity ratios. These demand-to-capacity ratios were plotted by circles of different sizes at the
locations of nursing homes (Figure 6).
In Figure 6, the larger circles show locations where there were more demands than
capacity. There did not seem to be significant differences between the results of applying the
two criteria. Similarly, the maps for the current senior population are also included as a base-
line reference.

FIGURE 6
ESTIMATED NURSING HOME DEMANDS AND CAPACITY

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 4. CONCLUDING REMARKS

With minimal assumptions for changes in the future trends of population distribution
in Cuyahoga County, Ohio, this paper examines how the spatial configuration of existing
nursing homes matches with the geographic pattern of the senior population. It is possible to
assess the overall match between nursing homes as service centers and senior population as
demands. With location-allocation analysis, a feasible approach to identifying any excess or
insufficient capacity with given distributions of demand was outlined and demonstrated.
However, it should be pointed out that this study can be improved by incorporating additional
procedures for projecting senior populations more precisely, such as adding the inward/outward
migration ratios of the senior population in a region. With proper information, such an
extension can be easily achieved with simple modifications to the procedures in the analysis.
Distance from senior residents to the nearest nursing homes was the primary factor in
this analysis. This can be easily extended to including additional controlling factors, such as
additional attributes of nursing homes, weighted distances by transportation modes, etc. While
more variables may be included in the analysis for more precise results, the overall procedures
and algorithms should remain similar, if not the same. Similarly, the same approach and
procedures may be used to address other types of services. This includes hospitals, health
clinics, or even retail centers.
Using location-allocation analysis, it is possible to assess how the current capacity
fares against potential demands. This assessment goes beyond simple numeric projections with
results that can be mapped to show the geographic patterns. From this analysis, not only can it
be determine if existing nursing homes possess excessive or insufficient capacity but also
where these surplus and shortfall occurs. This can assist policy makers in evaluating current
and future trends of needs for nursing homes.
The differences between results from location-allocation analysis by applying the
minimum distance criterion and by applying the maximum coverage criterion are minimal.
While the minimum distance criterion seems to be more efficient in deriving compact spatial
configuration, the advantage it offers over the maximum coverage criterion is only nominal. In
addition, the minimum distance criterion does not require the definition of a pre-set distance
threshold as required by the maximum coverage criterion.
If should also be noted that this study is subject to similar potential for ecological
fallacy of aggregation of spatial data as many other studies that utilize census data. While there
are no other alternatives because of the budgetary and time constraints that this study faced, it
is suggested that discussion by Goodchild (1979) and Casillas (1987) can be useful in
recognizing problems related to using aggregated data for analysis such as location-allocation.
Finally, it is also possible to improve the precision of similar studies by using smaller
geographic units such as census block groups or even census blocks. With the proliferation of
GIS technology, the increasing computational speed and the decreasing cost for digital storage,
it should be feasible to carry out studies similar to ours but with smaller geographic units over
larger geographic extent.

5. REFERENCES

Bishop, C.E. 2004. Paid Home Care in the 21st Century: Need and Demand. Home Health
Care Management & Practice 16(5):350-359.
Casillas, P. 1987. Aggregation problems in location-allocation modeling. In: Spatial Analysis
and Location-Allocation Models. A. Ghosh and G. Rushton, G., eds. Stroudsburg,
PA: Van Nostrand Reinhold.
ESRI. 2007. Census 2000 TIGER/Line Data. http://www.esri.com/data. Last accessed on
2007 December 12.
Ghosh, A., and F. Harche. 1993. Location-allocation models in the private sector: progress,
problems, and prospects. Location Analysis 1(1):81-106.

281
Goodchild, M.F. 1979. The aggregation problem in location-allocation. Geographical
Analysis 11:240-255.
GoogleEarth. http://3d-birdseyeview.com/index.php. Last accessed on 2007 December 12.
Hakimi, S.L. 1965. Optimum distributions of switching centers in a communication network
and some related graph theoretic problems. Operations Research 13:462-475.
Harper, P., A. Shahani, J. Gallagher, and C. Bowie. 2005. Planning health services with
explicit geographical considerations: a stochastic location-allocation approach. The
International Journal of Management Science 33:141-152.
Knickman, J.R., and E.K. Snell. 2002. The 2030 problem: caring for the aging baby
boomers. Health Services Research 37(4):849-884.
Kumar, N. 2004. Changing geographic access to and locational efficiency of health services in
two Indian districts between 1981 and 1996. Social Science and Medicine 58:2045-
2067.
Lee, J., and D. Wong. 2001. Statistical Analysis with ArcView GIS. New York: Wiley &
Sons.
Mulvey, J., and B. Stucki. 1998. Who Will Pay for the Baby Boomers’ Long-Term Care
Needs? Expanding the Role of Long-Term Care Insurance. Research Report.
Washington, DC: American Council of Life Insurance.
Ness, J., A. Ahmed, and W.S. Aronow. 2004. Demographics and Payment Characteristics of
Nursing Home Residents in the United States: A 23-Year Trend. Journal of
Gerontology 59A(11):1213-1217.
ReVelle, C.S., and R.W. Swain. 1970. Central facilities location. Geographic Analysis 2:30-
42.
ReVelle, C. 1991. Siting ambulances and fire companies: new tools for planners. Journal of
the American Planning Association 57(4):471-484.
Rice, D.P., and N. Fineman. 2004. Economic implications of increased longevity in the United
States. Annual Review of Public Health 25: 457-473.
Schneider, E.L. 1999. Demographics: Aging in the Third Millennium. Science,
283(5403):796-797.
UCHC 2007. UCompareHealthcare. The UCompareHealthCare, LLC. http://www.
ucomparehealthcare.com. Last accessed 2007 July 24.
U.S. Census Bureau. 2000. Census 2000. http://www.census.gov. Last accessed 2007 July
24.
Yeh, A.G., and M.H. Chow. 1996. An integrated GIS and location-allocation approach to
public facilities planning: An example of open space planning. Computers,
Environment, and Urban Systems 20: 339-350.
Zedlewski, S.R., and T.D. McBride. 1992. The changing profile of the elderly: effects on
future long-term care needs and financing. The Milbank Quarterly 70(2): 247-275.

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