A recent study found that a nurse practitioner/community health worker intervention was a feasible and acceptable strategy for addressing how social determinants of health (SDOH) and comorbidities influence chronic obstructive pulmonary disease (COPD) self-management.
In a study published in BMC Pulmonary Medicine, researchers found that an intervention led by a nurse practitioner (NP)/community health worker (CHW) team helped patients with chronic obstructive pulmonary disease (COPD) get emotional support and solutions to their unmet social determinant of health (SDOH) needs.
A mixed-methods study was conducted with an explanatory sequential design through which the researchers used qualitative data to provide insight into the characteristics of patients with COPD who were frequently hospitalized. The study was conducted at the Boston Medical Center (BMC), New England’s largest safety-net hospital that serves a substantial population of patients from underserved communities.
An advisory panel of clinicians, a CHW, and BMC hospital leaders decided, after reviewing data from 2018, that a longitudinal intervention that included a pulmonary NP to deliver evidence-based COPD care and a CHW to address unmet SDOH needs was necessary. This intervention took place from January to June 2019.
The researchers used the BMC Clinical Data Warehouse to identify adults 18 years and older admitted to the hospital or clinical observation unit between January 1 and December 31, 2018, with COPD. Patients were identified as having COPD by International Classification of Diseases, Tenth Revision codes and/or COPD on discharge lists. Data were collected on demographics, smoking status, comorbid conditions associated with readmissions, and number of admissions. Multivariable logistic regressions were also performed to identify factors associated with 2 or more admissions.
The researchers identified 70 participants from a list of patients scheduled in the NP’s clinic, who were mostly those recently discharged from the hospital with COPD as a diagnosis. The researchers additionally collected data on perceived support, cigarette use, stress, anxiety, depression, and substance use, all of which could affect COPD self-management, and assessed SDOH needs [CM1] using the THRIVE screening tool.
The NP/CHW intervention included 57 patients with COPD who were admitted 2 or more times and reported at least 1 unmet SDOH need. The NP/CHW team kept logs tracking the number of patients engaged during hospitalization and post discharge and recorded tasks completed. The feasibility metrics assessed in the logs included total time spent by the NP/CHW on each patient, tasks completed for each patient, and ability to engage the patient in program.
The researchers also gathered qualitative data from semistructured interviews in the same time frame with 16 participants purposely selected based on varying unmet SDOH needs and level of engagement in the intervention.
Among 1811 patients admitted with COPD in 2018, 776 had 2 or more admissions with a median (interquartile range) of 12 (6-22) days in the hospital. Medicaid-insured patients had 70% higher odds of 2 or more admissions (adjusted odds ratio [AOR], 1.7; 95% CI, 1.1-2.7). Patients with mental health disorders (AOR, 1.5; 95% CI, 1.1-1.9), cardiac disease (AOR, 2.0; 95% CI, 1.5-2.8), and substance use disorders (AOR, 1.8, 95% CI, 1.4-2.4) had increased odds of 2 or more admissions.
Of the 70 patients identified from a list of patients scheduled in the NP’s clinic following hospital discharge, 19 could not be reached and another 9 were excluded because they did not meet the criteria of 2 or more admissions a year, leaving 42 participants who completed the THRIVE screening. Of these, 74% of participants screened positive for unmet SDOH needs, 87.0% expressed interest in help with resources, and 75% expressed interest in meeting a CHW to address needs.
There were 57 patients who participated in the initiative during admission. The most common tasks completed during hospitalization included providing COPD education, facilitating scheduling in pulmonary clinics, arranging transportation for medical appointments, and providing tobacco treatment. The NP/CHW logs identified commonly performed postdischarge tasks as providing tobacco treatment and COPD education, providing transportation, and facilitating scheduling for medical appointments. Other postdischarge tasks included arranging food assistance and addressing other unmet SDOH needs and connecting to medical care.
The NP was able to meet with 36 patients within 14 days of hospital discharge. The NP spent 2 to 4 hours per patient per week and the CHW spent approximately 4 hours per patient per week.
In the qualitative analysis, key themes from the interviews included that (1) COPD severity, unmet SDOH needs, comorbid illness, and health literacy contributed to poor self-management; (2) patients were receptive to help addressing these factors but thought clinicians would be unable to adequately address them; and (3) patients had positive experiences with the CHW.
In the interviews, patients identified poor access to transportation, inability to afford medications, and limitations to daily activities, among others, as key barriers to effective self-management. All patients described the NP/CHW intervention as helpful in addressing barriers to COPD self-management and had positive remarks on the NP/CHW team providing tailored COPD management, providing quick access to medical care, providing support, and connecting resources for unmet SDOH needs.
There were some limitations to this study. It had a small sample size and a single site, which limits generalizability. Findings from participants who volunteered may not reflect perspectives from all individuals. This evaluation focused on assessing feasibility and acceptability of the initiative but was not designed to comment on clinical effectiveness.
The researchers wrote that their findings identified that it is essential for COPD discharge bundles in hospitals to serve marginalized populations to address how SDOH and comorbidities influence COPD self-management.
“Our longitudinal NP/CHW intervention appears to be a feasible and acceptable strategy to intervene on these factors and is responsive to the American Thoracic Society’s call for interventions to address SDOH needs for patients with COPD,” the researchers concluded.
Kearney L, Wiener RS, Dahodwala M, et al. 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. BMC Pulm Med. Published online March 1, 2022. doi:10.1186/s12890-022-01863-w