Academic clinical partnerships, home-based primary care, social determinants of health



  1. Coppa, Denise PhD, FNP-C, FAANP, FAAN (Associate Professor and Project Director, Academic-Clinical Partnership)


Background: The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data.


Purpose: The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH).


Methodology: Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes.


Results: Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded.


Conclusions: Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support.


Implications for practice: By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.