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

在美国，超过80%的65岁及以上的成年人至少有一种慢性健康状况。 种族和少数民族遭受的伤害更大。他们经常缺乏高质量的护理，并使用医院和急救 常规护理的科室(ED)。少数群体居住和接受护理的地方造成了健康差距。 他们通常生活在贫困社区，而健康的社会决定因素(SDoH)导致了差异。 少数族裔也在低质量的医疗保健环境中得到护理。由于初选，健康差距将进一步扩大 护理医生短缺。不断增长的护士从业者(NP)队伍可以帮助缩小健康差距，因为 NPS对少数族裔的照顾不成比例。然而，使用NP的实践(即，NP实践)经常被定位 在服务不足的社区，面临主要的结构(例如，缺乏登记)和组织(例如，贫穷) 护理环境)挑战。这项研究的主要目的是了解NP练习的方式 可以被用来解决SDoH和减少健康差距。在之前工作的基础上，我们将进行 第一个使用多水平模型、地理信息系统和实证研究的国家混合方法研究 实现目标的偏离方法：目标1.调查SDoH(即，经济稳定， 教育、建筑环境、医疗保健机会和社会背景)对种族和民族质量差异的影响 护理过程(例如，糖化血红蛋白检测糖尿病)和结果(例如，ED的使用、住院) 长期接受NP实践护理的老年人)。目标2.评估NP做法的程度 属性(即护理环境、结构能力)适度影响SDoH对种族和民族的影响 护理过程的质量和患者结果之间的差异。目标3.探索障碍和促进者 在具有不同护理环境和结构的NP实践中解决SDoH和健康差异 能力。我们将使用现有的关于社区和由非政府组织照顾的慢性病医疗保险患者的数据 2021-2022年在少数群体和非少数群体服务和综合国家方案实践中(n=2 400)。我们还将调查 NPS(n=6,960)在这些实践中使用邮件和在线方式对其护理环境和结构能力进行调查 方法：研究方法。有关患者、社区、NP和实践的所有数据将在多个层次上进行合并和分析 模特们。我们还将确定具有有利和不利护理环境和结构的做法 能力和面谈的NP和业务经理使用积极的偏离方法。我们将进行 对约50名NP和约50名业务经理进行了单独的电话/在线采访，这些业务经理来自于 以及~35名NPs和~35名经理，他们来自具有不利属性的实践。采访将被记录下来 并转录用于内容分析。我们将确定实践中的可修改因素，以解决SDoH问题。总而言之， 为了达到研究目的，我们将过度抽样为少数族裔服务的NP实践。我们的定量和定性结果将是 向寻求利用NP实践的管理人员和政策制定者提供信息，以解决 通过实践、政策和邻里干预，减少种族和民族健康差距。

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.