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Table 4 Tasks completed by NP/CHW team

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

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

 

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

 

6 (CHW)

 • Work with patients to organize and prioritize bill payment for both medical and non-medical bills

  

Arrange assistance with utilities

 

6 (CHW)

 • Write letters to utility companies to ensure heat, gas and water provided to patients’ residences

  

Provide assistance with housing

 

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

 

5 (NP and CHW)

Arrange non-invasive ventilation/oxygen with DME

11 (NP and CHW)

5 (NP)

Facilitate Scheduling of PFTs

 

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

 

7 (CHW)

  1. Per inclusion criteria, all 57 patients had COPD, ≥ 2 admissions and ≥ 1 unmet SDOH need
  2. 35/57 were individuals who currently smoke cigarettes
  3. CHW, community health worker; MHD, mental health disorder; NP, nurse practitioner; NRT, nicotine replacement therapy; PFT, pulmonary function tests; PT-1, Provider Request for Transportation form; SUD, substance use disorder