Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Jeffery Burr

Second Advisor

Kathrin Boerner

Third Advisor

Robert Weech-Maldonado


Nursing homes (NHs) have increasingly specialized in care. However, it remains unclear as to why NHs invest in certain type(s) of specialized care over the others and why some NHs invest more intensively than the others. Guided by Resource Dependence Theory and the Resource-Based View of Firms perspective, this study developed a NH care specialization typology and examined changes over time. Furthermore, this study examined the environmental and organizational characteristics of each care specialization group, as well as the relationship between care specialization groups and financial outcomes. This study employed NH-level panel data from 2011 to 2017 and focused on urban NHs. Multiple data sources were used for the analysis, such as Online Survey, Certification, and Reporting and Certification and Survey Provider Enhanced Reporting; Medicare Cost Reports, LTCfocus; Nursing Home Compare; and the Area Health Resources File. Latent profile analysis was employed to develop distinct NH care specialization groups. The results identified a four-group typology: the “low specialization” group, the “mixed specialization” group, the “moderate post-acute care (PAC) specialization” group, and the “intensive PAC specialization” group. Results from random-effects modeling with lagged outcomes indicated that NHs specialized in PAC at a higher degree when they were located in counties with higher Medicare Advantage expansion rates or in states more influenced by accountable care organizations. Ownership difference was evident regarding the relationship between care specialization groups and financial outcomes. In not-for-profit NHs, there was a weak relationship between care specialization groups and revenues or operating margins. In for-profit NHs, revenues increased as NHs showed a higher level of commitment to PAC specialization. However, being in a group with a higher level of commitment to PAC specialization was not necessarily associated with a higher operating margin in for-profit NHs. Further, analysis on NHs that experienced transitions between care specialization groups indicated transitioning to a higher level of PAC specialization group was in general not associated with better financial outcomes. Findings offer important implications for future research design and policies.


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