4.2.6: FRAME 6- Evaluate Outcomes

Before leaving the third visit, the nurse recognizes Stanley has lifelong habits that will require interventions to make changes to support a healthier lifestyle and decrease his hospital readmissions for COPD exacerbations. The nurse reflects on the physical assessment, community, and environmental assessment to identify community referrals to include in his home care plan.

Evaluate Outcomes

QUESTION: Matrix Multiple Choice

Scoring Rule: 0/1

After reviewing the notes, conducting a physical assessment, and a community and environmental assessment, what community referrals would be appropriate to include in Stanley’s home care plan? Each row should include a single choice.

Community Referral	Appropriate	Not Appropriate
Dietary consult
Pulmonary rehabilitation
Palliative care
Wound management
Smoking cessation
Dental care
Access to healthy food choices
Physical therapy
Meals on Wheels service
Transportation options
Sleep apnea evaluation

Putting It All Together

DEBRIEF

COPD is a leading cause of death and hospitalization in the United States. It has become increasingly evident that short-term approaches focusing on medical care during the immediate post-discharge period do not fully address factors contributing to readmission (Kearney et al., 2022). Adverse SDOH, the social circumstances in which people are born, grow, live, work, and age, increases the risk of readmissions and hospitalizations for clients with COPD (Kearney et al., 2022).

The home health nurse plays a significant role in decreasing disparities, comorbidities, and hospitalizations due to COPD exacerbations. The home health nurse can teach and reinforce self-management skills to the client.

Self-management interventions help individuals with COPD acquire and practice the skills they need to carry out disease-specific medication regimens, guide changes in health behavior, and provide emotional support to enable them to control their disease (Schrijver et al., 2022). Access to care, safe places to ambulate, and dust generated from driving on dirt roads in rural communities will require the nurse to be creative in developing COPD self-management strategies for Stanley.

RECOGNIZING SOCIAL DETERMINANTS OF HEALTH (SDOH)

Kearny et al. (2022) conducted a study to inform and evaluate nurse practitioner/community health worker (NP/CHW) interventions to address SDOH and COPD self-management to reduce disparities, improve quality care, and reduce hospitalizations. Kearney et al. (2022) identified that clients with Medicaid insurance, mental health disorders, cardiac disease, and substance use disorder had increased odds of having two or more admissions and that 74% of individuals with COPD were admitted to the hospital two or more times per year have unmet SDOH needs.

COPD severity, comorbidities, and unmet SDOH needs made COPD self-management challenging. Clients perceived that the NP/CHW intervention addressed these barriers by connecting them to resources and providing emotional support. Some factors impacting COPD self-management included social isolation, anxiety, depression, smoking, substance abuse, comorbidities, housing and food insecurity, lack of transportation to medical appointments, education needs, unemployment, difficulty paying for medications or utilities, caregiver issues, and a limited understanding of COPD (Kearney et al., 2022). Telehealth is a viable way to extend healthcare services to rural communities. Telehealth reduces barriers to care to help bridge the health disparities gap between urban and rural communities.

What Do You Think About?

1. Identify ways the nurse can tailor COPD self-management interventions to individual clients.
2. Compare how COPD selfmanagement interventions might differ in rural versus urban locations?
3. Discuss how telemedicine interventions can be utilized in COPD self-management for rural populations?