5.2.6: FRAME 6- Evaluate Outcomes

CORRECT Answer

Question Type: Matrix Multiple Choice

Scoring: 0/1

NCSBN Item Type and Scoring: https://www.ncsbn.org/public-files/p...main_stage.pdf

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

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

RATIONALE

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, increase 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. Selfmanagement interventions help individuals with COPD to 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, 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.

Components of Stanley’s care should include dietary consult and identifying healthy community food resources such as Meals on Wheels, pulmonary rehabilitation, palliative care, smoking cessation, dental care, sleep apnea evaluation and access to transportation to support adherence to referrals and self-management strategies.

FOCUSED GUIDE

Kearney 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) found 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 patients 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.