Impact of Nurse Practitioner Primary Care Models on Health Disparities among Persons Living With Dementia

/ABSTRACT Nationally, 6.9 million Americans ages 65 and older live with Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD). These Persons Living with Dementia (PLWD), have higher rates of unnecessary hospitalizations and emergency department (ED) visits than those without AD/ADRD. This gap in acute care utilization is more pronounced for PLWD in at-risk groups (i.e. low-income, rural, racial and ethnic groups). Primary care can improve outcomes, but physician shortages remain a barrier. Nurse practitioners (NPs), the fastest-growing primary care workforce, are key to the care of PLWD. The NP primary care model emphasizes patient-centeredness, care coordination, and social needs screening—beneficial features in the care of PLWD. NP primary care models for PLWD include NPs serving as main primary care providers (PCPs) delivering comprehensive primary care or NPs serving as ancillary PCPs providing discrete services (e.g., care coordination) to PLWD. The NP primary care models are largely invisible in administrative datasets, such as Medicare claims, because up to half of all NP care is billed incident-to a physician. In addition, primary care NPs are not distinguishable from specialty NPs because NPs lack specialty identifiers in claims. Our novel study applies new approaches, correcting for incident-to billing and the Primary Care Provider Identification Algorithm (PCP-IA), to uncover the NP primary care model in claims and examine its impact on health disparities among PLWD. The specific aims are: Aim 1. Identify PLWD receiving care in NP primary care models (i.e., NPs as main PCPs; NPs as ancillary PCPs) and assess for differences in the sociodemographic and racial and ethnic composition of PLWD across the models. Aim 2. Determine the effect of the NP primary care models on outcomes (i.e., all-cause and preventable hospitalizations and ED visits) of PLWD and evaluate which model moderates the racial and ethnic disparities in these outcomes. Using 2023 data for all Medicare beneficiaries, we will correct for incident-to-billing and apply our innovative PCP-IA to first identify primary care NPs. The PCP-IA applies 3 indicators to uncover the care model: 1) breadth of diagnoses managed, 2) predominant setting, and 3) extent of procedural care. We will then identify PLWD receiving care in two NP primary care models (i.e., NPs as main or ancillary PCPs) and show the differences in the racial and ethnic composition of PLWD receiving care across the models. With multilevel models, we will assess which NP primary care model is most effective in reducing racial and ethnic disparities in the health outcomes of PLWD. This application is responsive to the National Institute of Aging’s Research on Current Topics in Alzheimer's Disease and Its Related Dementias (PAR-25-331). As a priority of this mechanism, we leverage national data on all older adults with AD/ADRD in the US to produce foundational evidence for large-scale studies of NP care models that improve outcomes for PLWD. Project Number: 1R21AG095668-01A1 | Fiscal Year: 2026 | NIH Institute/Center: National Institute on Aging (NIA) | Principal Investigator: Monica O'Reilly-Jacob | Institution: COLUMBIA UNIVERSITY HEALTH SCIENCES, NEW YORK, NY | Award Amount: $452,375 | Activity Code: R21 | Study Section: Healthcare and Health Disparities Study Section[HHD] View on NIH RePORTER: https://reporter.nih.gov/project-details/11362905