A new study found that 74% of COPD patients admitted to the hospital two or more times per year have unmet social needs that could impede COPD self-management.

Longitudinal intervention with such patients by a health care worker led to fewer readmissions but no improvements in mortality or health-related quality of life.  These findings were recently published in BMC Pulmonary Medicine.

A mixed methods quality improvement initiative was undertaken by researchers from Boston Medical Center (BMC), a safety-net hospital for patients of low socioeconomic status, after a BMC program designed to reduce COPD readmissions was found to be ineffective. Researchers identified patients with unmet SDOH needs who were then followed by a nurse practitioner/community health worker team through one month post-discharge.

The researchers identified 1811 adults age 18 years or older admitted to BMC hospital or the clinical observation unit for COPD between January 1 and December 31, 2018. The investigators then screened these patients’ medical records for SDOH needs using a standardized instrument, the THRIVE screening tool. After a pilot program was instituted for those patients with unmet SDOH needs, the investigators gathered further data from nurse practitioner and community health worker logs and qualitative interviews.

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