Date of Publication
2023
Project Team
Teal Church, RN MSN Teresa Cahill-Griffin DNP RNC-OB
Abstract
Background: There is growing recognition that social determinants of health (SDoH)—the conditions in which people live, learn, work, play, and worship—can affect health and produce disparities (Thornton, 2016). The Nurse Navigator rebuilds a connection between high-needs patients and accessing healthcare. Key improvement areas were identified quickly via motivational interviewing with the seven participants with hypertension. All that participated but two had recorded blood pressures above the United States Preventative Preventative Task Force (USPSTF) recommendation. The Nurse Navigator intervention was designed to re-engage a historically underserved population in their healthcare by incorporating support for social determinants of health factors.
Methods: A retrospective chart review and consult were performed with 107 patients via phone or text outreach. Fourteen patients participated via telephone or in person, and eleven made follow-up care appointments after the intervention. Ten made appointments after only a text and four attended. Seven more people made preventative appointments from text outreach between January 2023 and April 2023. Participating patients fit the inclusion criteria of having a diagnosis of diabetes, hypertension, or COPD. Utilizing the Plan-Do-Study-Act quality improvement methodology, a Nurse Navigator interviewed fourteen patients willing to participate in determining gaps in patient knowledge, self-management, motivation for change, and knowledge of preventative screenings to increase follow-up care.
Results: One hundred seven patients met the selection criteria and were contacted for this intervention. Fourteen participants agreed to the consultation. Ten made appointments from text outreach only. Therefore twenty-two patients made follow-up care appointments out of those selected. The clinic saw an increase of 37% in attendance after the intervention. Target question scores increased overall following the intervention in psychosocial management, understanding, and goal setting. Question one concerning goal setting had a p-value of .0156, and the median score for the stand-alone question, “Do you feel these conversations helped manage, meet goals, or understand your current condition?” was 9.17.
Conclusions: This project showed that a Nurse Navigator could facilitate follow-up care appointments for patients whose SDoH may negatively impact their health outcomes. This intervention also demonstrates the potential for re-engaging patients at a free clinic is possible through education and consultation with a Nurse Navigator. This intervention also allows some patients to realize a readiness to change. Initial pilot program results indicate potential and a need for further investigation due to the time limit and demographics for the project.
Document Type
Project
Recommended Citation
Church, Teal, "Increasing Access to a Primary Care Free Clinic" (2023). College of Nursing and Health Sciences Clinical Nurse Leader (CNL) Project Publications. 7.
https://scholarworks.uvm.edu/cnhscnl/7
