Table 1.

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

	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