ETHICS AND THE DNP-PREPARED NURSE

Specific Aims

This article describes the implementation of a holistic model of integrated behavioral health at an NP-led primary care health center to address SDOH for residents of a vulnerable community in the city of Chicago. The collaborative care model was selected as the framework for healthcare delivery, as it is well-established in expanding opportunities for access to healthcare services, addressing health inequities, and improving health outcomes at the individual and population levels. 4  Additional interdisciplinary services were added to the model to meet the needs of the target population.

Local Problem

The community of focus is Humboldt Park, a neighborhood located on the west side of Chicago that is rich with green space, diversity, and community activism. It is also one of the most underserved communities in the city, designated as both a Primary Care and Mental Health Professional Shortage Area. 5  In 2018, there were 56,248 people living in Humboldt Park, 54.6% of whom were Hispanic, 37.2% non-Hispanic Black, and 5.8% non-Hispanic White. 6

Social Determinants Of Health: Available Knowledge

The Healthy People 2030 SDOH objective is divided into five topics: (1) Education Access and Quality, (2) Health Care Access and Quality, (3) Neighborhood and Built Environment, (4) Social and Community Context, and (5) Economic Stability. 2  Each of the SDOH subtopics also has an identified goal with evidence-based resources to support their achievement. Data measures available for Humboldt Park related to the five SDOH topics were obtained (see  SDOH measures of Humboldt Park community versus city of Chicago).

Education access and quality

The Healthy People 2030 goal for this topic is, "increase educational opportunities and help children and adolescents do well in school." 2  Data show that people who have not completed high school report higher rates of asthma, diabetes, heart disease, hepatitis, high BP, stroke, and stomach ulcers. 7  Within the Humboldt Park community, fewer people have graduated from high school or college as compared with the city of Chicago, considerably limiting employment opportunities. More than 20% of residents have limited English proficiency. 6

Healthcare access and quality

Although multiple community health centers serve Humboldt Park, substantial gaps remain that affect access to healthcare. The Healthy People 2030 goal for this SDOH measure is, "increase access to comprehensive, high-quality health care services." 2  Over 20% of the community's population does not have health insurance. 6  As a result, fewer community residents report receiving routine health examinations or dental cleanings. Many residents report unmet dental, optical, and prescription needs due to costs, while 10% report decreasing prescribed medication dosages to lessen their financial burden. 6  In Humboldt Park, only 58.1% of people report being satisfied with their healthcare, as compared with 68% of Chicago residents who reported feeling satisfied as of 2018. 6

Neighborhood and built environment

The Healthy People 2030 goal for the community-built environment is, "create neighborhoods and environments that promote health and safety." 2  Providing communities with access to sidewalks and bike lanes promotes healthy behaviors and improves the quality of life for residents. 2  However, exposure to crime and violence is associated with fear for personal safety, and can result in negative health outcomes. 2,8  Fearing for one's safety limits outdoor physical activity and also increases levels of mental stress. 8  Humboldt Park has green space, sidewalks, and bike lanes, but has a violent crime rate nearly twice that of the city of Chicago. 6  Less than 50% of community residents report feeling safe in their neighborhood all or nearly all of the time, compared with 86% of residents in the community on its east border. 6 Residential housing in Humboldt Park is higher-density when compared with the city of Chicago overall, yet 46.1% of community residents have a high-cost burden, as they report spending more than 35% of their total income on housing. 6 While 67.8% of Chicago residents report easy access to fresh fruits and vegetables, only 56.9% of Humboldt Park residents report the same. 6

Social and community context

The Healthy People 2030 goal for this SDOH topic is, "increase social and community support." 2  The quality of one's relationships with family, friends, and community members affects one's individual health outcomes. 2  Access to social support for adults, adolescents, and children reduces mental health stress and promotes health-seeking behaviors. 2 Experiencing adverse life circumstances such as incarceration can result in decreased family and community support for the incarcerated individual and their children. 2  Within this community, nearly 50% of adult males report having ever been arrested, with 35.5% reporting having ever been incarcerated. 6  56.2% of community adult residents state that they have been stopped by the police when they did not believe there was a legitimate reason for them to be stopped. 6

Economic stability

The Humboldt Park community faces significant challenges related to financial stability, with many residents having experienced homelessness, food insecurity, and unemployment. 6  These issues are addressed in Healthy People 2030 under the topic of economic stability, with a goal to, "help people earn steady incomes that allows them to meet their health needs." 2  In comparison to the city of Chicago, nearly twice the percentage of households in Humboldt Park live below the federal poverty level. 6,7  Food insecurity rates for Humboldt Park residents disproportionately impact children and minorities. 9  The uncertainty of access to adequate food is reflected in the fact that 49% of households in the community received supplemental nutritional assistance for purchasing groceries and 30% used emergency food access, such as soup kitchens and food pantries in 2018. 10  In Humboldt Park 47% of adults are obese, substantially higher than the national average of 29.5%. 10

Physical and mental health of the community

SDOH are linked to both the physical and mental health outcomes of a community. 2  Compared with other communities in Chicago, Humboldt Park residents have a lower life expectancy; higher rates of obesity, diabetes, and asthma and deaths due to heart disease; and a low ranking of perceived good health (see  Physical and mental health measures in Humboldt Park community as compared with city of Chicago). 6,11  The community of Humboldt Park also has a high rate of opioid use and opioid-related deaths due to overdose. 5,6

Rationale

There are numerous evidence-based strategies to address and improve population health outcomes. One approach is to provide access to comprehensive and holistic care within a community of focus using the collaborative care (CC) model of integrated behavioral health, developed by the University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center. 4  Consistent outcomes from more than 90 published studies of the CC model demonstrate decreased rates of depression and anxiety and improvements in comorbidities such as heart disease and diabetes as compared with usual care. 4  Important core concepts of the CC model are a team-based approach to patient care and measurement-based treatment that combines behavioral health and primary care using evidence-based treatment modalities. Patient progress is rigorously tracked and monitored using a dedicated AIMS web-based data registry to ensure that changes to treatment are implemented when key patient outcome measures have not improved. Medications to manage common behavioral health disorders, such as depression and anxiety, are prescribed and managed by primary care providers with the expertise and support of psychiatric mental health care providers.

Methods

Context

The primary care health center in which CC was implemented is a nurse-managed center located in the community of Humboldt Park, serves as a faculty practice site, and provides interprofessional learning opportunities for students across disciplines. The college of nursing operates the center, which is one of a large network of federally qualified health centers (FQHCs). FQHCs are safety net healthcare providers with an obligation to serve people who are underinsured or uninsured and are financially supported by a federally funded enhanced service reimbursement model. 12

Between July 2019 and June 2020, the center served 1,213 distinct patients, 41% of whom identified as Black, 34.5% as Hispanic, and 15.4% as White. The remaining 9.1% self-identified as Asian, two or more races, or documented that they preferred not to answer the question. Patients served included 54% men and 46% women. The majority of patients were insured through a Medicaid-managed care plan. Prior to the implementation of the CC model, the health center operated under a traditional primary care model whereby a person's physical health needs were met by the primary care provider and behavioral health needs were addressed by internal or external psychiatric specialists without meaningful professional collaboration. The AIMS CC model was selected for implementation by organizational leadership based on studies clearly demonstrating that integrated primary and behavioral care significantly improved both healthcare access and quality-of-care outcomes in FQHC clinics. 4

Intervention

CC model implementation

Implementation of CC within the center was facilitated with the expert support of the University of Washington AIMS Center. Through CC, behavioral health becomes not just an additional medical service, but part of a comprehensive care model, achieved by a structured organizational process including both primary care and behavioral healthcare providers for ongoing patient-care collaboration. This is a core principle of the CC model, as it supports patient-centered care at one access site that increases both patient engagement and satisfaction with their healthcare. 4  Prior to implementation of the CC model, the healthcare team did have behavioral health members but there was no collaborative patient-care management with primary care providers. Following implementation, and consistent with the model developed by the AIMS Center, it is comprised of primary care providers (PCPs) who are family NPs, a behavioral health consultant (BHC) who is a licensed clinical social worker with a certification in drug and alcohol counseling, a psychiatric consultant who is a psychiatric mental health NP, an RN, and clinic support staff (see  Collaborative care team at the center). The staff and CC team at the center reflect the racial and ethnic makeup of the patient population.

Additional patient services

Humboldt Park has a high rate of opioid overdose deaths, three times the rate of the city of Chicago, the majority involving fentanyl. 4,6  Over the past 2 years, primary and psychiatric nurse NPs have completed federally mandated training to increase community access to opioid use disorder (OUD) treatment through medication-assisted treatment (MAT) and counseling. As waivered practitioners, they can prescribe buprenorphine, an FDA-approved medication considered the gold standard for OUD treatment.

Two interdisciplinary professionals added to support the CC team are a pharmacist and dietitian. The clinical pharmacist works one-to-one with patients to answer their medication questions, as well as providing education to the PCP and BHC regarding psychiatric medication prescription and management. The dietitian provides individual nutritional counseling-both in person and via telehealth visits-to reverse the population's high rates of obesity and diabetes. The dietitian has also been integral to addressing community food insecurity by providing patients with access to food resources. The implementation of the CC team-based model has been iterative, and occurred over 3 years (see  Timeline of implementation of CC model of care figure, Supplemental Digital Content 1 at  http://links.lww.com/NPR/A12 ).

Patient visit structure

The CC model uses a standardized process for each patient encounter. Patients are universally screened for depression and anxiety at each primary care visit using the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) tools. Patients with a positive screen for either tool, or presenting with a behavioral health concern, are introduced to the CC model and offered behavioral health services by the PCP. If the patient agrees, a comprehensive assessment is done by the BHC, and a plan of care is formulated based on the patient's specific needs. The therapeutic interventions are intended to be short-term and include psychotherapies shown to be effective in the primary care setting. 4  Patients complete the PHQ-9 and GAD-7 screening tools at each subsequent clinic visit to evaluate their progress. The psychiatric consultant works with the PCP and BHC to ensure that treatment is effective and assists the PCP with medication management. The care team meets biweekly for case consultation and educational sessions.

The BHC assists with care coordination and resource referral to address patients' financial, physical health, and social-emotional needs such as connecting them to emergency and long-term food resources, access to transportation and state and county health insurance resources, employment opportunities, assistance with disability and unemployment benefits, and appeals for denial of benefits with legal support (see  Behavioral health consultant: Care coordination activities table, Supplemental Digital Content 2 at  http://links.lww.com/NPR/A11 ).

Measures

Goals of the Healthy People 2030 initiative include a focus on improving both access to healthcare services for underserved communities and populations and providing high-quality, evidence-based preventive care in a timely manner. 13  Outcome measures selected to evaluate the implementation of the CC model at this clinic related to SDOH included:

* Access to behavioral health and MAT for OUD;

* Comparison of pre- and posttreatment PHQ-9/GAD-7 screening scores;

* Primary healthcare outcome measures;

* Access to nutrition counseling and food resources.

Results

Access to behavioral health and MAT for OUD

Prior to the initiation of the CC model, the center did not offer OUD treatment. After implementation of the BHC position, between October 2018 and December 2020, 320 patients received BHC services, with 70 active patients as of December 2020. Of the active patients, 83% received at least one monthly contact with the BHC during their treatment. Before September 2019, the center did not offer MAT. Between September 2019 (when MAT was initiated at the center) and December 2020, 49 patients have been prescribed buprenorphine, with 31 active patients receiving MAT as of December 2020. Each of the current 31 patients has had an average of 7.2 visits since initiating MAT. Patients are monitored using a registry and receive care management from a nurse care manager.

Comparison of PHQ-9/GAD-7 scores pre- and posttreatment

Patients who engaged in the CC model experienced improvements in their depression and anxiety symptoms, as demonstrated by 23% of the current caseload having at least a 50% reduction or nonclinically significant screening score on the PHQ-9, and 36% at least a 50% reduction or nonclinically significant score on the GAD-7 following initial treatment in CC (data from October 2018 to December 2020).

Primary healthcare outcome measures

The center participates in the Uniform Data System (UDS), a federal repository that collects and reports standardized quality metrics about health centers. Results from the 2019 UDS report document that center patients have improved outcomes related to body mass index (BMI) likely a result of nutrition education (75%), and that rates of screening for tobacco use (93%), cervical cancer (70%), and depression (97%) are higher than national averages (see  UDS comparisons). Notably, rates of colorectal cancer screening are 54% at the center, significantly higher than the 2019 UDS national average of 45.56%. 14

Access to nutrition counseling and food resources

From May 2020 to December 2020, 50 patients had encounters with the dietitian. While all nutrition visits included an assessment of food security, six of these visits were specific to links for patients identified as food-insecure to provide immediate access to a local resource for groceries. The center staff also assist patients from low-income households with applications to receive monthly, state-subsidized benefits for a nutritionally healthy diet.

Ethical Considerations

The University of Illinois Chicago Office for the protection of research subjects determined that this quality improvement initiative did not meet the definition of research as defined in 45 CFR 46.102(l).

Interpretation

The CC model improved patient access to comprehensive healthcare by providing physical and mental health services via one care team. A comprehensive care team allows patients to contact only one health center when in need, facilitating continuity of care. 4  Integration of behavioral and primary care through the CC model is cost-effective and has better patient outcomes as compared with standard care, in addition to possibly reducing the stigma related to seeking mental health treatment. 4

Patients who engaged in the CC model showed improvements in both depression and anxiety screening tool scores. Patients receiving MAT had on average 7.2 visits, which included visits related to buprenorphine management as well as primary care visits; at each visit, the PCP holistically assessed patient health status. Patients developed relationships with the care team, strengthening community connections to the center. When care teams are interdisciplinary, patients gain access to experts who can immediately address needs within a familiar and trusted setting, as evidenced by the integration of a dietitian and BHC at the center. The dietitian was able to identify reliable food resources to make direct and immediate connections for those in need. In addition, care coordination by the BHC with referrals to community-based resources targeted individual patient needs.

Limitations

Our data reflect the implementation of the CC model at one community health center, limiting the generalizability of the outcomes. Additionally, an unanticipated shift in care delivery from in-person visits to telehealth in March 2020 due to the COVID-19 pandemic may have influenced results.

Summary

This quality improvement initiative exemplifies an innovative response to the National Academies report,  The Future of Nursing 2020-2030. 15  The report calls for nurses to practice to the full extent of their education and training and lead improvements in healthcare access, quality, and equity. 15  Due to their holistic approach, nurses are uniquely positioned to incorporate the physical, mental, and social healthcare needs of individual patients. This nurse-led team used the CC model to address SDOH by enhancing the availability, accessibility, and acceptability of primary and behavioral healthcare-a first step toward achieving health equity and improving health outcomes for vulnerable people and communities.

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Keywords: collaborative care; federally qualified health centers; integrated behavioral health; nurse-managed health centers; primary care; social determinants of health