Mental health conditions, particularly substance use disorders, are a growing public health threat that affect millions of Americans. Drug use disorders (DUDs), a subset of substance use disorders, are chronic conditions characterized by clusters of behavioral, cognitive, and physiological symptoms related to the use of opioids, hallucinogens, stimulants, cannabis, anxiolytics/hypnotics/sedatives, inhalants, multiple drugs, other drugs, or unknown drugs.
The prevalence of DUDs among older adults ages 65 and older is growing. In 2021, almost 2 million older adults in the United States (U.S.) had a DUD. DUDs have a detrimental effect on health, especially among older adults with DUDs, who are more likely to have comorbid chronic conditions such as chronic obstructive pulmonary disorder, diabetes, and chronic heart failure than older adults without DUDs or other age groups with DUDs. The medications and symptoms of these comorbid conditions can interact with DUD-associated drugs and cause high risk for falls, delirium, medication interactions, chronic disease exacerbations, and acute emergency department (ED) utilization.
Thus, in addition to the alarming growth in the prevalence of DUDs in older adults, this population faces additional risks for poor health and acute ED utilization.Despite similar prevalence of DUDs among rural and urban older adults, older adults in rural areas have decreased access to DUD care. In rural areas, there is lower availability of DUD specialists and treatment centers. In 2019, 1,149 rural counties did not have a provider who could prescribe buprenorphine (a medication for opioid use disorder), compared to only 57 urban counties. Rural residents must drive an average of 49.1 minutes to receive DUD treatment, compared to just 7.8 minutes for urban residents.
Enhanced availability of DUD treatment in primary care settings may fill the gap in access to mental health and substance use care in rural communities as older adults seek primary care providers for other routine care. Prior studies have shown that patients who seek and receive pharmacologic or psychological interventions in primary care settings may have improved DUD outcomes such as lower rates of relapse, increased retention in treatment, and abstinence. The Affordable Care Act increased funding for rural primary care practices to deliver integrated mental and physical health care, which may improve outcomes for older adults with DUDs.
Yet, many rural older adults with DUDs do not receive DUD screening and treatment in primary care. Presently, only 45% of patients are screened for DUDs in the community. Primary care providers often report that they do not have the confidence to address DUDs. While some research shows that organizational support such as DUD-specific training and clinical resources are key to improving primary care provider confidence in addressing opioid use disorder, there is very little research focused on the unique needs of rural primary care providers in delivering DUD services. Research on organizational factors that influence the availability and quality of DUD services in rural primary care practices is needed to bolster primary care capacity to serve older adults with DUDs in rural areas.
Rural primary care practices increasingly rely on the growing nurse practitioner (NP) workforce to deliver care.
Over one-quarter of the rural primary care workforce is NPs. Most research on the rural primary care NP workforce and DUD services focuses on NP prescribing of buprenorphine, a medication for opioid use disorder. Half of the new buprenorphine providers in rural areas are NPs, and NPs treat more patients with buprenorphine than physicians in rural areas.
Despite NPs’ contribution to DUD care for rural patients, studies show that many NPs practice in challenging work environments that negatively impact their ability to deliver patient care. The NP work environment is often characterized by a lack of resources, autonomy, and support, which affects the delivery of patient-centered care, high-quality care, and health services utilization among patients with chronic conditions. Studies have suggested that work environment factors such as teamwork and autonomy may influence NP prescribing of buprenorphine. Yet, no studies have focused on NP work environments in primary care practices and how they affect care for older adults with DUDs in rural areas.
The overall purpose of this dissertation is to produce evidence on enhancing the primary care NP workforce’s ability to deliver mental health and DUD services. The first study in this dissertation (Chapter 2) was a systematic review of the literature focused on the effectiveness of NP care for patients with mental health conditions (i.e., anxiety, depression, and substance use disorders) in primary care settings. These conditions were included to identify the state of the literature base focused on NP mental health care delivery in primary care settings, particularly focused on gaps in evidence related to NP care for rural older adults with DUDs. The second study in this dissertation (Chapter 3) conceptualized primary care provider confidence in addressing opioid use disorder to understand how to support providers (i.e., physician, NPs, and physician assistants) in delivering DUD care through policy, practice, and research innovations. The third study of this dissertation (Chapter 4) assessed the relationship between the NP work environment and rural NP practices’ capacity to serve older adults with DUDs. Finally, the fourth study (Chapter 5) examined the impact of the NP work environment in rural primary care practices on ED utilization among older adults with DUDs. Findings from the studies included in this dissertation can be used to improve primary care delivery in rural areas and inform policy and research innovations to address the growing public health threat of DUDs among rural older adults.
Materials and Methods
This dissertation utilized novel materials and methods to inform the development of policy, practice, and research innovations that enhance the primary care NP workforce’s ability to deliver mental health and DUD services. The following presents the study design of each individual chapter to achieve the study’s aims.
Study 1 | Chapter 2: This systematic review of the evidence addressed the effectiveness of NP care for patients with mental health conditions in primary care settings. We followed Joanna Briggs Institute (JBI) Manual for Evidence Synthesis for systematic reviews of effectiveness and reports results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol is published with PROSPERO (ID = CRD42021269816).
Study 2 | Chapter 3: This concept analysis followed the Walker and Avant framework to conceptualize primary care provider confidence in addressing opioid use disorder.
Study 3 | Chapter 4: The goal of this study was to assess the impact of the NP work environment on the capacity of rural primary care practices to serve older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using fractional logistic regression.
Study 4 | Chapter 5: The goal of this study was to examine the association between the NP work environment and ED utilization among older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using multilevel logistic regression.
Conclusions
This dissertation produced evidence that enhances the primary care NP workforce’s ability to deliver mental health and DUD services. In Chapter 2, the systematic review of the literature identified a lack of high-quality research focused on NP primary care for patients with mental health conditions, particularly among patients with substance use disorders in rural areas. Chapter 3 conceptualized primary care provider confidence in addressing opioid use disorder and found that teamwork, organizational culture, resources, and support may uniquely influence provider confidence, which is associated with positive patient outcomes, increased delivery of and access to opioid use disorder services, and provider attitude changes. In Chapters 4 and 5, our studies found that the NP work environment in rural primary care practices is associated with increased practice capacity to serve older adults with DUDs and reduced ED utilization in this population. These dissertation findings provide important insights that will allow policymakers, practice administrators, and researchers to invest in productive efforts to enhance the primary care NP workforce’s ability to deliver mental health and DUD services.
| Identifer | oai:union.ndltd.org:columbia.edu/oai:academiccommons.columbia.edu:10.7916/8s0b-1t68 |
| Date | January 2023 |
| Creators | Turi, Eleanor |
| Source Sets | Columbia University |
| Language | English |
| Detected Language | English |
| Type | Theses |
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