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.
