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。 少数种族和族裔遭受的苦难更大。他们往往缺乏高质量的护理， 常规护理部门（ED）。少数群体居住和接受护理的地方造成了健康差距。 他们通常生活在弱势社区，健康的社会决定因素（SDoH）导致了差异。 少数群体也在低质量的医疗机构中获得护理。健康差距将进一步扩大， 医生短缺。不断增长的执业护士（NP）劳动力可以帮助减少健康差距， NPs不成比例地照顾少数民族。然而，采用NP的做法（即，NP实践）通常位于 在服务不足的社区，并面临重大的结构性（例如，缺乏登记册）和组织（例如，贫困 护理环境）挑战。这项研究的首要目标是了解NP实践的方式 可以用来解决SDoH和减少健康差距。在我们先前工作的基础上，我们将开展 第一个全国性的混合方法研究，使用多层次模型，地理信息系统，和一个积极的， 实现目标的偏离方法：目标1。调查SDoH的影响（即，经济稳定， 教育、建筑环境、医疗保健获得和社会背景）对种族和族裔质量差异的影响 护理过程（例如，糖尿病的HbA 1c检测）和结果（即，艾德使用、住院） 在NP实践中接受护理的慢性老年人）。目标2.评估NP实践的程度 属性（即，护理环境，结构能力）缓和SDoH对种族和民族的影响 护理过程和患者结果的质量差异。目标3.探索障碍和促进因素， 解决不同护理环境和结构的NP实践中的SDoH和健康差异 能力的我们将使用现有的数据对社区和慢性病的医疗保险病人照顾的NP 在2021-2022年，少数民族和非少数民族服务和综合NP实践（n= 2，400）。我们还将调查 在这些实践中，NP（n= 6，960）使用邮件和在线方式了解其护理环境和结构能力 方法.所有关于患者、社区、NP和实践的数据将在多层次中合并和分析。 模型我们还将确定有利和不利的护理环境和结构的做法 能力和采访NP和实践经理使用积极的偏差方法。我们会进行 对来自实践的约50名NP和约50名实践经理进行了单独的电话/在线访谈， 和~35名NP和~35名管理者来自具有不利属性的实践。采访会被录音 并转录用于内容分析。我们会找出在实践中可修改的因素，以解决可持续卫生问题。在所有 研究的目的，我们将过抽样少数民族服务的NP的做法。我们的定量和定性研究结果将 进行三角分析，为管理人员和政策制定者提供信息， SDoH和减少种族和民族的健康差距，通过实践，政策和邻里干预。

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.