2025 Theses Doctoral

Expanding and Supporting the Primary Care Nurse Practitioner Workforce to Improve Health Outcomes for Communities and Patients with Language Needs

Horton, Madison Diana

The population with language needs in the U.S. has grown substantially due to increased immigration, language diversification, and persistent structural barriers to education and employment that perpetuate linguistic isolation. This demographic shift pressures healthcare systems to adapt and provide more language-accessible care, as patients with language needs experience worse health outcomes than English-proficient patients. Primary care involves continuous, coordinated healthcare services that range from preventive, routine, and chronic disease care management. Access to primary care services prevents unnecessary acute care utilization and promotes health equity for underserved populations, including those with language needs. However, increasing demands, workforce shortages, and unsupportive care environments within primary care practices serving patients with language needs challenge the delivery of high-quality primary care.

Nurse Practitioners (NPs) are a fast-growing workforce of primary care providers who provide safe, high-quality care, especially to patients residing in underserved areas. Therefore, the NP workforce is well-positioned to help meet the increasing demand for primary care for those with language needs and make primary care more accessible in communities with language needs. When NPs work in supportive care environments, patients receive higher-quality care and have improved health outcomes; however, most NPs work in poor care environments, which may limit their ability to meet the language needs of communities and individuals.

To our knowledge, no study has explored patient outcomes in NP primary care practices in communities with language needs or assessed how NP care environments influence differences in patient outcomes related to caring for patients with language needs. The dissertation aimed to address these gaps by evaluating the effectiveness of NPs as primary care providers for communities with language needs and identifying ways to best support NPs caring for patients with language needs to reduce health disparities. The overall purpose of this dissertation is to produce evidence on expanding and supporting the primary care NP workforce to improve health outcomes for communities and patients with language needs.

In Chapter 1, we provide an overview of the unique healthcare needs of patients and communities with language needs and the role of NPs and supportive work environments in improving access to primary care and reducing reliance on acute care services.

In Chapter 2, existing evidence on the impact of primary care service delivery on acute care utilization (emergency department (ED) visits, hospitalizations, and readmissions) and access to care for patients with LEP was synthesized. Nine studies met the inclusion criteria. Primary care services (i.e., interpreters, language-concordant providers, and telehealth) reduced ED utilization and readmissions for patients with LEP, but did not significantly impact hospitalizations. During the COVID-19 pandemic, patients with LEP faced disparities in access to care. Our synthesis suggests that ensuring reliable access to language services in primary care practices is essential to meet the needs of patients with LEP and to reduce health disparities.

In Chapter 3, we performed a secondary data analysis of an existing cross-sectional dataset containing information on Medicare beneficiaries, including demographic characteristics, ED and hospitalization use, and data on the percentage of households with LEP in communities where primary care practices are located. This was a merged dataset of Medicare data with American Community Survey data, resulting in a sample of 506,516 Medicare beneficiaries receiving primary care services at 895 NP-employing practices located in communities with varying percentages of households with LEP, ranging from 0.0% to 72.4%, We assessed whether the percentage of households with LEP in communities where NP primary care practices are located is associated with ED use and hospitalization among older adult patients receiving care at these practices. We found that receiving care at NP practices located in communities with a higher percentage of households with LEP was associated with a significantly lower incidence of ED visits and a marginally significantly lower incidence of hospitalizations among older adults. Our findings suggest that the NP workforce is essential to increasing access to primary care in LEP communities and reducing reliance on acute care services.

In Chapter 4, we assessed how the NP work environment moderates the relationship between the likelihood of primary care practices caring for non-English speaking (NES) patients and ED visits and hospitalizations. Across 596,677 Medicare beneficiaries receiving care in 1,042 primary care practices, we found that as the NP work environment improved, the positive association between practices reporting a higher likelihood of caring for NES patients and higher acute care use weakened. Our findings provide novel evidence that improved NP work environments can significantly weaken or eliminate health disparities related to caring for NES patients.

In Chapter 5, we conclude with a summary of the findings and provide practice, policy, and research implications aimed at enhancing the accessibility of health services to communities and patients with language needs and fostering more supportive NP care environments for safe and high-quality care. We also discuss the strengths and limitations of this dissertation.