Table 4.
Tasks completed by NP/CHW team
| 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) | |
Per inclusion criteria, all 57 patients had COPD, ≥ 2 admissions and ≥ 1 unmet SDOH need
35/57 were individuals who currently smoke cigarettes
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