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Table 1 Elements of COPD nurse practitioner (NP)/community health worker (CHW) intervention

From: A mixed methods study to inform and evaluate a longitudinal nurse practitioner/community health worker intervention to address social determinants of health and chronic obstructive pulmonary disease self-management

 

COPD readmission reduction NP tasks

CHW tasks

During hospital

Schedules a follow-up visit within 3–14 days of hospital discharge

 • Presents options for pharmacotherapy based on smoking behaviors and cravings (derived from ATTUD training)

Provides tobacco treatment to individuals who smoke cigarettes

 • education on how to use medications

 • personal COPD action plan

 • how to recognize COPD exacerbations

 • the hospital discharge plan

Provides bedside COPD education and personalized COPD action plan that includes:

Connects patients to tailored resources based on unmet SDOH needs

Provides tobacco treatment to individuals who smoke cigarettes

 • Presents a menu of options for pharmacotherapy based on smoking behaviors and cravings (derived from ATTUD training)

Arranges follow-up visit with pulmonary NP within 3–14 days of hospital discharge

Post-discharge

Continues to work with pharmacy, durable medical equipment (DME), Visiting Nurse Association, PCP, and specialists to ensure safe discharge

Available to address medical questions (both patients and families) and advise when a patient needs to come into clinic, emergency room, or hospital to receive medical care for COPD or comorbid illnesses

Provides ongoing tobacco treatment to individuals who smoke cigarettes

Provides tailored education and self-management training to ensure that patients understand the plan provided as an inpatient

Explores SDOH-related issues that are barriers to accessing and engaging in COPD care

Connects patients to resources to address unmet SDOH needs

Explores the patient’s prior experience with COPD treatment and brainstorms strategies to improve adherence

Provides navigation to help patients access medical care

Provides ongoing tobacco treatment to individuals who smoke cigarettes

Works flexible hours, contacting patients on evenings/weekends as needed