The Impact of Nurse Practitioner Work Environment and Community Characteristics on Acute Care Utilization by Older Adults with Multiple Chronic Conditions

Multiple chronic conditions (MCCs), defined as two or more chronic conditions in the same person, are more common and costly that any individual health condition in the United States (US). Yet, people with MCCs often receive primary care that is condition-centric and fragmented, leading to duplicative tests, adverse drug events, and conflicting medical advice. Such inadequate primary care leads to frequent emergency department (ED) visits and hospitalizations for exacerbations of these chronic conditions. Social determinants of health, including low income and poor primary care availability, further worsen patients’ burden of MCCs. Across the nation, particularly in communities with poor socioeconomic resources, few physicians enter and stay in primary care while the large and growing workforce of nurse practitioners (NPs) provide safe, cost-effective primary care in these underserved areas. However, there is a gap in evidence regarding how primary care practices can support NPs to meet the complex care needs of people with MCCs. Poor NP care environments, marked by lack of support for NP practice, collegiality between clinicians, and an organizational understanding of the NP role, deplete organizations of financial and human resources through burnout and turnover, challenging NPs’ ability to provide care for people with MCCs. Positive NP care environments are associated with quality care for chronic disease and may help alleviate the negative impact of poor community characteristics on patients through optimal teamwork, support, and communication. Yet, to date, no study has investigated the impact of NP care environment on the relationship between community characteristics and outcomes for people with MCCs. To fill this critical gap in evidence, this dissertation will leverage an existing dataset from a study conducted by my mentor (R01MD011514 PI: Poghosyan, 2016-2022) which contains information on NP care environments across six states merged with 1) Medicare claims (i.e., patient characteristics, ED visits, and hospitalizations), 2) the Socioeconomic Position Index created from US Census Bureau data, and 3) Primary Care Service Area files indicating primary care service availability. My aims are to: Aim 1: Assess NP care environments and community characteristics (i.e., socioeconomic position and primary care availability) of practices caring for patients ≥65 years with MCCs. Aim 2: Investigate the relationship between NP care environment, community characteristics, and acute care utilization (i.e., ED utilization and hospitalizations) among patients ≥65 years with MCCs and determine if care environment moderates the relationship between community characteristics and acute care utilization. I will have access to ample research infrastructure at Columbia University, and I am supported by an exceptional mentorship team with expertise in NP workforce, MCCs, multilevel modelling, and dissemination of findings. This study will produce evidence to improve health for socially and economically marginalized older adults living with MCCs, an Agency for Healthcare Research and Quality priority population.