Enhancing Nurse Practitioner Primary Care Delivery to Address Social Determinants of Health and Reduce Health Disparities: A mixed-methods national study

加强执业护士初级保健服务，以解决健康的社会决定因素并减少健康差异：一项混合方法的国家研究

• 批准号: 10591788
• 负责人: Lusine Poghosyan
• 金额: $ 75.87万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-07 至 2027-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10591788
• 关键词: Accident and Emergency department; Address; Administrator; Adult; Affect; Area; COVID-19 pandemic; Care given by nurses; Caring; Chronic; Chronic Care; Chronically Ill; Community Services; Competence; Coupled; Data; Diabetes Mellitus; Disparity; Economics; Education; Elderly; Ensure; Environment; Face; Future; Genetic Transcription; Geographic Information Systems; Glycosylated hemoglobin A; Health; Health Services; Health Status; Healthcare; Healthcare Systems; Hospital Departments; Hospitalization; Hospitals; Individual; Insurance Carriers; Intervention; Interview; Investments; Lead; Medicare; Medicare claim; Methods; Minority; Modeling; Neighborhoods; Nurse Practitioners; Outcome; Patient Care; Patient-Focused Outcomes; Patients; Persons; Play; Policies; Policy Maker; Population; Primary Care; Primary Care Physician; Primary Nursing Care; Process; Public Health; Quality of Care; Reduce health disparities; Registries; Reminder Systems; Resources; Role; Sampling; Service delivery model; Social Environment; Structure; Surveys; System; Telephone; Testing; Translating; US State; United States; Work; behavioral health; built environment; care delivery; care systems; clinical care; design; disease registry; ethnic disparity; ethnic health disparity; ethnic minority; health care availability; health care quality; health care settings; health data; health disparity; health equity; health professional shortage areas; human old age (65+); improved; innovation; minority patient; multilevel analysis; neighborhood disadvantage; older patient; payment; population health; prevent; primary care practice; racial disparity; racial health disparity; racial minority; routine care; social group; social health determinants; therapy design; underserved area; underserved community

More than 80% of adults aged 65 and older in the United States have at least one chronic health condition. Racial and ethnic minorities suffer more. They often lack high quality care and use hospitals and emergency departments (EDs) for routine care. Where minorities reside and receive care contribute to health disparities. They often live in disadvantaged neighborhoods, and social determinants of health (SDoH) lead to disparities. Minorities also get care in low quality healthcare settings. Health disparities will further widen due to primary care physician shortages. The growing nurse practitioner (NP) workforce can help reduce health disparities as NPs disproportionately care for minorities. Yet, practices employing NPs (i.e., NP practices) are often located in underserved communities and face major structural (e.g., lack of registries) and organizational (e.g., poor care environments) challenges. The study’s overarching aim is to understand ways in which NP practices could be leveraged to address SDoH and reduce health disparities. Building on our prior work, we will conduct the first national mixed-methods study using multilevel models, geographic information system, and a positive- deviance approach to achieve the aims: Aim 1. Investigate the impact of SDoH (i.e., economic stability, education, built environment, health care access, and social context) on racial and ethnic disparities in quality of care processes (e.g., HbA1c testing for diabetes) and outcomes (i.e., ED use, hospitalizations) among chronically older adults receiving care in NP practices). Aim 2. Assess the extent to which NP practice attributes (i.e., care environment, structural capabilities) moderate the impact of SDoH on racial and ethnic disparities in quality of care processes and patient outcomes. Aim 3. Explore barriers and facilitators to addressing SDoH and health disparities in NP practices with varying care environments and structural capabilities. We will use existing data on neighborhoods and chronically ill Medicare patients cared for by NPs in 2021-2022 in minority- and non-minority serving and integrated NP practices (n=2,400). We will also survey NPs (n=6,960) in these practices on their care environments and structural capabilities using mail and online methods. All data about patients, neighborhoods, NPs, and practices will be merged and analyzed in multilevel models. We will also identify practices with favorable and unfavorable care environments and structural capabilities and interview NPs and practice managers using positive-deviance methods. We will conduct individual telephone/online interviews with ~50 NPs and ~50 practice managers from practices with favorable and ~35 NPs and ~35 managers from practices with unfavorable attributes. The interviews will be recorded and transcribed for content analysis. We will identify modifiable factors in practices to address SDoH. In all study aims, we will oversample minority-serving NP practices. Our quantitative and qualitative findings will be triangulated to inform administrators and policymakers seeking ways to leverage NP practices to address SDoH and reduce racial and ethnic health disparities through practice, policy, and neighborhood interventions.

在美国，超过 80% 的 65 岁及以上成年人至少患有一种慢性疾病。 少数种族和族裔遭受的苦难更多。他们往往缺乏高质量的护理，只能使用医院和急诊室 进行日常护理的部门 (ED)。少数群体居住和接受护理的地方会造成健康差异。 他们通常生活在贫困社区，健康社会决定因素 (SDoH) 导致了不平等。 少数族裔也在低质量的医疗环境中获得护理。由于初级教育问题，健康差距将进一步扩大 护理医师短缺。不断增长的执业护士 (NP) 队伍可以帮助缩小健康差距，因为 NP 不成比例地关心少数群体。然而，使用 NP 的实践（即 NP 实践）通常位于 在服务不足的社区，面临重大的结构性（例如，缺乏登记）和组织性（例如，贫困） 护理环境）挑战。该研究的首要目标是了解 NP 实践的方式 可以用来解决 SDoH 问题并减少健康差距。在我们之前工作的基础上，我们将开展 第一个国家混合方法研究使用多层次模型、地理信息系统和积极的 目标 1. 调查 SDoH 的影响（即经济稳定、 教育、建筑环境、医疗保健获取和社会背景）有关种族和民族质量差异的问题 护理过程（例如糖尿病的 HbA1c 检测）和结果（即急诊室使用、住院治疗） 长期在 NP 实践中接受护理的老年人）。目标 2. 评估 NP 实践的程度 属性（即护理环境、结构能力）调节 SDoH 对种族和民族的影响 护理过程质量和患者结果的差异。目标 3. 探索障碍和促进因素 解决不同护理环境和结构下 NP 实践中的 SDoH 和健康差异 能力。我们将使用有关社区和由 NP 照顾的慢性病医疗保险患者的现有数据 2021-2022 年少数族裔和非少数族裔服务和综合 NP 实践（n=2,400）。我们还将进行调查 在这些实践中，NP (n=6,960) 使用邮件和在线方式了解他们的护理环境和结构能力 方法。有关患者、社区、NP 和实践的所有数据都将进行多级合并和分析 模型。我们还将确定具有有利和不利护理环境和结构的做法 能力并使用正偏差方法采访 NP 和实践经理。我们将进行 对约 50 名 NP 和约 50 名来自具有有利条件的实践的实践经理进行单独电话/在线访谈 约 35 名 NP 和约 35 名管理者来自具有不利属性的实践。访谈将被记录 并转录以进行内容分析。我们将确定实践中可修改的因素来解决 SDoH。总共 研究目标，我们将对少数族裔服务的 NP 实践进行过度抽样。我们的定量和定性研究结果将是 三角测量，以告知管理员和政策制定者寻求利用 NP 实践来解决问题的方法 SDoH 并通过实践、政策和邻里干预措施减少种族和民族健康差异。