A. Complete barrier assessment linked to socioeconomic resources |
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Assessment of need for assistance with employment and income, family and social support, transportation to healthcare facilities, housing, utilities (e.g., heat, light), food, and interpersonal violence.
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Barriers selected based on the Society of Hospital Medicine's Project BOOST,16 and interviews with stakeholders (patients, caregivers, clinicians, administrators at UI Health).
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As appropriate, review barriers with the participant's clinician and social worker.
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B. Offer and assist with participant-specific needs by helping patients to identify and receive assistance from resources |
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Development of a tailored, patient-centered plan for solutions to each identified barrier. Resources included those available through Purple Binder (website that houses information for medical and social service resources in the Chicago area) and those used by the hospital's social work department.
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Review of solutions with the participant during subsequent visits and/or through email and text messages.
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Reassessment of barriers and identification of new ones during each CHW in-hospital encounter.
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Caregivers included in the discussions if requested by participant.
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C. Completion of a “Discharge Patient Education Tool” |
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Completion of personalized discharge patient educational tool (DPET) based on discharge instructions in the electronic health records.
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Core content areas reviewed with participant using teach-back:
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Post-discharge follow up visits and tests,
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Recommendations regarding lifestyle changes, and - Use of medications after discharge.
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CHW scheduled post-discharge follow-up appointments as needed.
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Review of previously-identified barriers and potential solutions, including post-discharge resources and services.
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Scheduling of home visit of CHW within 3 business days of hospital discharge.
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Referral to the participant's clinicians for medical advice.
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D. Re-review the DPET with the participant |
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During home visit, review of DPET with the participant, including:
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Reminder of upcoming tests and appointments
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Confirmation of availability of transportation to tests and appointments
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Review understanding and adherence to lifestyle changes
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Confirmation of availability of medications
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Confirmation of understanding and adherence to medications
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If the participant had difficulty adhering to the DPET, peer coached identified new barriers and worked with participant to find a solution.
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Participants encouraged to contact the hospital's social worker or clinician's office, if needed.
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E. Re-review solutions to barriers with patient |
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Review solutions implemented for previously identified barriers.
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If needed, identification of new barriers and potential solutions
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F. Peer coaching |
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Introduction of peer-coaching intervention prior to hospital discharge.
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Reminder about upcoming phone-based peer coaching calls during the home visit.
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Peer coaches had access to barriers and solutions identified by CHW through study data system.
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