Tasks/services provided | Number of patients assisted while hospitalized (by whom) | Number of patients assisted post-discharge (by whom) |
---|---|---|
Tobacco treatment (n = 35 who currently smoke cigarettes) | ||
Smoking Cessation counseling | 35 (NP and CHW) | 27 (NP and CHW) |
Facilitate pharmacotherapy (Chantix, NRT) | 24 (NP and CHW) | 19 (CHW) |
SDOH concrete assistance (n = 57 patients) |  |  |
Arrange transportation | 41 (CHW) | 35 (CHW) |
 • Fill out form (PT-1) to secure non-emergency medical transportation for patient |  |  |
 • Call to set up transportation through free services in the city for appointments |  |  |
 • Work internally within BMC to explore transportation options |  |  |
Arrange food assistance | Â | 21 (CHW) |
 • Provide prescriptions for hospital-based food pantry |  |  |
 • Connect with community-based food pantry |  |  |
 • Find patients turkeys or grocery store gift cards during the holidays |  |  |
Arrange assistance with bill payments | Â | 6 (CHW) |
 • Work with patients to organize and prioritize bill payment for both medical and non-medical bills |  |  |
Arrange assistance with utilities | Â | 6 (CHW) |
 • Write letters to utility companies to ensure heat, gas and water provided to patients’ residences |  |  |
Provide assistance with housing | Â | 8 (CHW) |
 • Write letters of support for patients with detrimental housing situations- (e.g. mold) |  |  |
COPD management (n = 57 patients) | ||
Education | 57 (NP) | 36 (NP) |
Facilitate pulmonary rehabilitation | Â | 5 (NP and CHW) |
Arrange non-invasive ventilation/oxygen with DME | 11 (NP and CHW) | 5 (NP) |
Facilitate Scheduling of PFTs | Â | 24 (NP and CHW) |
Appointment scheduling (n = 57 patients) | ||
Facilitate scheduling in pulmonary clinic | 57 (NP and CHW) | 48 (NP and CHW) |
Arrange appointments in SUD/MHD clinics | Â | 7 (CHW) |