Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients

Abstract

Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients Ani Bilazarian BackgroundPrimary care practices in the United States (US) are currently constrained in their ability to deliver high quality care due to population aging, insurance expansion, and an increasing prevalence of chronically ill patients. The nurse practitioner (NP) workforce plays a critical role in meeting the growing demands for primary care, particularly in rural and underserved areas.NPs are also more likely to deliver care to clinically and socially complex populations such as high-need high-cost (HNHC) patients. HNHC patients are adults who suffer from multiple chronic conditions and experience additional functional, behavioral, or socioeconomic needs.Despite comprising only 5% of the US population, HNHC patients account for nearly half of total health care expenditures and over 90% of Medicare expenditures. HNHC patients with behavioral health diagnoses such as depression or substance abuse face heightened challenges managing their conditions and consequentially have higher preventable spending and emergency department (ED) utilization compared to the overall HNHC population.Significant policy attention has been placed on enhancing primary care practices as a strategy to improve outcomes and reduce costs in HNHC patients. Structural capabilities are features of primary care practices (e.g., after-hours care or care coordination) which are needed to deliver high quality primary care and chronic disease management. Yet, to date little research has been done on structural capabilities in primary care practices where NPs deliver care to HNHC patients. The overall purpose of this dissertation is to understand how to enhance primary care delivery and structural capabilities to improve outcomes for HNHC patients. We have achieved the following specific aims: (1) Establish a clear definition of HNHC patients, (2) Identify existing primary care and payment models used among HNHC patients and evaluate their impact on ED utilization and costs, (3) Evaluate structural capabilities in NP primary care practices located in Health Professional Shortage Areas (HPSAs), and ( 4) Analyze the association between NP practice structural capabilities and ED utilization among HNHC patients with behavioral health conditions. Dissertation Chapters and Key FindingsChapter One includes an introduction to the landscape of current primary care delivery, the role of the NP workforce in expanding access, and the unique challenges of delivering care to HNHC patients. This chapter also discusses the conceptual framework guiding the dissertation, the specific aims of each study, and how each study will fill a gap in the literature.Chapter Two (Aim 1) consists of a concept analysis of HNHC patients using the Walker and Avant framework. Three subgroups of HNHC patients were identified: adults over the age of 65 who suffer from multiple chronic conditions with functional or behavioral health needs, the frail elderly,...