The Influence of Primary Care Structural Capabilities on Hospitalizations among Older Adults with Dementia

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Currently, 5.8 million Americans have Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD). As the segment of the United States population age 65 and older continues to grow, the number of Americans with AD/ADRD and the use of health care services such as hospitalizations will also increase. Hospitalizations are more prevalent among older adults with AD/ADRD compared to older adults without AD/ADRD. Some of these hospitalizations are considered potentially avoidable if individuals have better access to and quality of primary care. However, delivering high quality primary care is becoming increasingly challenging given the projected shortage of primary care physicians. On the other hand, the number of nurse practitioners (NPs) has grown in the recent years and will increase by 93% by 2025. Further, NPs deliver high- quality and cost-effective care to older adults. Yet, little is known about how to support NPs' ability to deliver high quality care. Particularly, little is known about how to strengthen structural capabilities, essential practice features needed for delivering high quality of care, in practices where NPs provide care to older adults with AD/ADRD. Enhancing primary care delivery through strengthening structural capabilities such as care coordination, the Electronic Health Record (EHR), and community integration in primary care can be an effective potential way to reduce hospitalizations among older adults with AD/ADRD. The overall objective of the proposed study is to assess the effects of primary care structural capabilities in practices employing NPs on both all-cause and potentially avoidable hospitalizations among Medicare beneficiaries with AD/ADRD. This dissertation study will use unique cross-sectional data produced in 2018-2019 from a large National Institutes of Health-funded study and its associated Alzheimer's supplement (PI: Poghosyan, R01 MD011514-03S1). The following specific aims are proposed: Aim 1. Describe structural capabilities (i.e., availability of care coordination, EHR, and community integration) in primary care practices where NPs provide care to Medicare beneficiaries with AD/ADRD. Aim 2. Assess the impact of structural capabilities in primary care practices employing NPs on potentially avoidable and all-cause hospitalizations among Medicare beneficiaries with AD/ADRD. We hypothesize that more structural capabilities will be associated with lower hospitalizations among Medicare beneficiaries with AD/ADRD compared to practices with fewer structural capabilities. Multi- level linear regression models will be used to assess the impact of structural capabilities on hospitalizations among older adults with AD/ADRD. Findings from this study will generate evidence about how structural capabilities may improve primary care delivery for older adults with AD/ADRD. The proposed study is well- aligned with the mission of the National Institute of Aging to identify ways to reduce illness burdens such as hospitalizations among those with AD/ADRD. In addition, this R36 study will allow a pre-doctoral student to develop the skills needed to become an independent health services researcher.