Application of a Heuristic Framework for Multilevel Interventions to Eliminate the Impact of Unjust Social Processes and Other Harmful Social Determinants of Health.

There is consensus about the importance of developing a strong cadre of effective multilevel interventions to eliminate the impacts of unjust social processes, such as structural racism and other harmful social determinants of health (SDOH), on health inequities in the USA. However, the available cadre of rigorously evaluated evidence-based interventions for SDOH mitigation remains underdeveloped relative to the magnitude of historic and current health inequities. The proposed manuscript addresses this gap in two ways: first, by introducing a heuristic framework to inform decisions in multilevel intervention development, study design, and selection of analytic methods and, second, by providing a roadmap for future applications of the framework in multilevel intervention research through an exemplar application using the ongoing NIH-funded evaluation study of the Nurse-Community-Family Partnership (NCFP) intervention. NCFP leverages individual, family, institutional, and system factors to shape COVID-19 mitigation outcomes at the individual and household levels. NCFP takes an approach informed by the heuristic framework to addressing and mitigating unjust social processes and other harmful SDOH. We discuss the application of a two-arm parallel explanatory group randomized trial to evaluate the efficacy of NCFP in improving the primary (COVID-19 testing uptake) and secondary (adoption of COVID-19 control measures, COVID-19 vaccine uptake, mutual aid capacity, etc.) outcomes at the individual and household levels. The analysis approach relies on random-intercept models, and we calculate the variance partitioning coefficient to estimate the extent to which household- and individual-level variables contribute to the outcome, allowing examination of NCFP effects at multiple levels.

Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid.

BACKGROUND: Medicaid payment reforms and delivery model innovations are needed to fully transform U.S. healthcare structuring and provision. PURPOSE: To synthesize nurse-led models of care and their implications for improving health care access, quality, and reducing costs for Medicaid recipients. METHODS: A critical review of the literature regarding nurse-led models and implications for addressing social determinants of health (SDOH), adopting population health approaches, managing complex care, and integrating behavioral and physical health care within Medicaid. DISCUSSION: Three interrelated findings emerged (a) investing in dynamic nurse-led models is important for mitigating SDOH and adopting value-based care, (b) regulations preventing nurses from practicing at the fullest extent of their training and licensure limit clinical impact and value, and (c) directed payments can establish value-based expectations for Medicaid managed care. CONCLUSION: Adoption of a nurse-led model of care has the potential to advance the goals of reducing inequity and promoting whole-person health within Medicaid and nationally.

Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications.

BACKGROUND: The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity. PURPOSE: Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce. METHODS: We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles. FINDINGS: To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic. DISCUSSION: Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.