Essay Examples - Self-Care Deficit Model in the Development of a Pre- Discharge Education Program (PDEP)

Are you wondering “how can I write my essay?” Read this example to get some ideas:

Abstract

The Pre-Discharge Education program (PDEP) is identified as an effective pre-discharge and post-discharge intervention on readmission rates for COPD patients. The applied theoretical framework is Dorothea Orem’s Self-Care Deficit Theory (Fawcett, 2001). The steps to implement PDEP for COPD patients are addressed in this evidence based paper. The paper also includes information regarding the theoretical framework to guide this project and methods to evaluate this program.

Introduction

Chronic obstructive pulmonary disease (COPD) affects millions of Americans in North America and is the third leading cause of death in this country (American Lung Association, 2014). According to Healthy People 2020 (2014), nearly 13.6 million adults have been diagnosed with COPD, making this disease a source of health care costs and preventable admissions. Chronic obstructive pulmonary disease (COPD) can be a debilitating disease and impacts the quality of life for patients, their families, and their community (Harrison, Auerbach, Quinn, Kynoch, & Mourad, 2014). The financial ramifications due to Chronic obstructive pulmonary disease (COPD) include fiscal costs to care for these patients, elevated health insurance costs, and lost productivity (Healthy People 2020, 2014). There is very little difference in the number of COPD deaths and cancer deaths; 120, 000 people died due to COPD and 158, 600 died of cancer in 2006 (Healthy People 2020, 2014).

Linden and Butterworth (2014) suggested that evidence from 43 studies in a systematic review of interventions to reduce readmissions, have shown that PDEP is associated with enriched quality of care. It should be noted that examined interventions, used components found in a transitional care model. Incorporated components included patient education, discharge planning, medication reconciliation, and post discharge components including follow-up telephone calls and patient-centered discharge instructions (Linden & Butterworth, 2014).

This project will seek to introduce a PDEP program for COPD patients in a Community Hospital, to minimize 30 day readmission rates. However, unlike previous interventions this evidence based project will solely focus on pre-discharge education and post discharge follow-up intervention components. Therefore, results may vary from previous intervention approaches. The pre-discharge education is based on an assessment of the patients’ knowledge and ability. Further, self-care following discharge will be provided in order to prevent readmission within 30 days of discharge.

The PICOT question is, “In adult patients diagnosed with COPD and having chronic dyspnea, how effective would pre-discharge education, post discharge telephone follow-up, and weekly nurse home care nurse visits be in reducing readmissions for chronic dyspnea, as compared to brief discharge instructions (current standard of care) over a 30 day period?”

Theoretical Support

The application of Orem’s Self-Care Deficit Model has been determined to be a suitable theoretical framework, to guide the Pre-Discharge Education Program (PDEP). The concepts of Orem’s Care Model can be found in Appendix A. Orem’s model for implementation is broken down into four phases. These four phases are critical in the education and assessment of patients. The four phases illustrated in Appendix A, are essential to pre and post-discharge strategies for reducing COPD readmission rates. They include assessment, planning, implementation, and evaluation (Bieda, Centopanti, & Callaghan, 2012).

Orem defines the first phase assessment, as the ability to determine the individual qualities a person possesses, enabling them to collaboratively achieve therapeutic self-care. The individual qualities that Orem references are known as power components (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014). Power components are understood as the capacity of an individual to meet self-care needs. Appendix B provides power components that can be useful in assessing COPD patients. There are nine recommended power components, including self-management of physical activities, reasoning capacity, and decision-making capabilities (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014).

Orem defines planning as the process for determining who can or should perform the self-care operations of a patient. The PDEP program will evaluate whether the patient requires wholly compensatory, partly compensatory, or supportive-educative (The University of Tennessee at Chattanooga School of Nursing Faculty & Students, 2014). By conducting the assessment phase, the nurse will have sufficient information from the functional assessment to determine the appropriate level of service that the patient requires. The systematic implementation and evaluation of the PDEP program may reduce readmission rates for patients with chronic dyspnea, as compared to brief discharge instructions.

The Initial Steps

This pilot program will take place at Palisades Medical Center in North Bergen, New Jersey. Approximately 5.1 percent of New Jersey residents surveyed in 2011 have been informed by a healthcare professional that they have COPD. According to a recent survey, certain residents have a higher proclivity to have COPD symptoms. One highly susceptible group is unemployed females’ age 65-74 years old, who are either divorced or widowed. Also, individuals that have a minimal annual income of less than $25, 000 are at greater risk for COPD. Finally, individuals with a history of smoking or a history of asthma have a greater proclivity (Center for Disease Control and Prevention, n.d.).

The Palisades Medical Center is selected to launch this pilot (PDEP) program, due to their demonstrated commitment to establish high-quality COPD programs. Palisades Medical Center has received National Certification from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), for their Cardiovascular Rehabilitation program. The pulmonary rehabilitation program for Palisades includes Chronic Obstructive Pulmonary Disease (COPD). The program currently incorporates exercise, education, counseling, and support for patients. Those programs with AACVPR certification are identified as leaders in the field of pulmonary rehabilitation. Palisades has identified a 25 percent increase in patients requiring Cardiovascular and Pulmonary Rehabilitation services (Palisades Medical Center, 2015).

Also, Palisades serves approximately 400,000 patients located in Hudson and Southern Bergen Counties. With an annual operating budget of $150 million dollars it has been ranked as one of the premier hospitals in the State of New Jersey and #1 in Hudson County. It is also ideal for the launching of the PDEP program for patients with Chronic Obstructive Pulmonary Disease because it has a perfect 100 percent score in treating heart attack patients. Finally according to New Jersey’s annual evaluation Palisades has zero deficiencies for the third consecutive year (Palisades Medical Center, 2015).

Step one-Approach to Stakeholders

Palisades Medical Center (PMC) will be contacted to set up an appointment with key members of the Board of Governors. Current board members include Theresa de Leon Esq. (Chairwoman), Andrew Horowitz (Vice Chairman), Leonard Lauricella (Treasurer), Kevin O’Connor (Secretary), Bruce J Markowitz (President), Jeffrey Raskin, MD (Medical Staff President), and Aida Capo, MD (Medical Staff President-Elect) (Palisades Medical Center, 2015).

The PMC Board of Governors will be presented with information regarding the PDEP program. Discussion will include explaining how effective intervention will further enhance existent Chronic Obstructive Pulmonary Disease (COPD) practices. Given PMC’s current National recognition as a leader in the treatment of Cardiovascular and Pulmonary Rehabilitation, full support of the PDEP program is anticipated. However, statistical data concerning COPD patients, costs, and the value of education-based intervention, will also be presented to strengthen the case.

One of the presented benefits of the PDEP program will be the potential to reduce costs associated with readmission of Chronic Obstructive Pulmonary Disease (COPD) patients. The Centers for Medicare and Medicaid Services (CMS) extended its Hospital Readmission Reduction Program (HRRP) by adding COPD to their list of admissions that would penalize hospitals if a patient is readmitted with the same condition. This means that all COPD readmissions in the 30 days post discharge will not be reimbursed and hospitals will have to absorb the costs (Feemster, & Au, 2014).

To further strengthen the case for establishing a robust PDEP program, there will be statistics presented from literature review on previous interventional studies. In nearly eight out of ten cases, COPD is caused by exposure to cigarette smoke (Healthy People 2020, 2014). These studies and available literature support the use of continued reinforcement and education of the benefits of smoking cessation. Pulmonary rehabilitation was strongly recommended along with care and management of patients at home to improve the quality of life and minimize readmission rates. As much as possible, patients with COPD should be treated at home with supportive care, rather than remain in a hospital (Lynes, 2010).

Supportive care at home for patients with COPD was a common effective intervention in the studies used to support the PICOT question. In the studies, supportive care was provided by interventions such as a home care visit from a nurse, a follow-up telephone call, and a video telemedicine conference with the patient by the nurse.

Also, the board will be provided information regarding a double blind peer reviewed intervention. This study by Matthews, Toole, Nicholls, & Lindsey-Halls, (2013) elected 298 patients for a 12 month care bundle study. After education and nursing interventions the results in this study were as follows: 39 percent of patients stopped smoking after four weeks, a total of 13 fewer readmissions occurred in an eight month period (£30,277 was saved, which is equivalent to £45,415 a year in English currency), and all patients were able to correctly self-administer oral inhalers (Mathews et al., 2013). The authors suggest these results reveal the importance of education and referral to a pulmonary rehab program as soon as possible prior to discharge from the hospital to prevent readmissions.

The Pilot Program

The Pilot Program will consist of a Nurse Practitioner to provide consulting and facilitation of the PDEP program, a nurse to do bedside teaching including breathing exercises and proper inhaler use, and a respiratory therapist to provide breathing treatment and general patient support. The PDEP program will include an initial education in pulmonary rehabilitation and Self-Management. It will also include the provision of a written personalized COPD action plan. That will be further supported by monthly telephone calls, and three monthly home visits by a specialist nurse over a two-year period.

Pilot time-frame

The pilot program will run for six months to provide ample time for data collection and examination of factors like COPD exacerbation and readmission rates.

The six month time frame is further supported by success associated with previous comprehensive hospital-based intervention programs for chronically ill patients. A recent study with 512 patients suffering from (CHF) congestive heart failure was conducted within a 90 day period. Therefore, the six month time period enables researchers to examine data at the halfway point and make any necessary adjustments that are necessary (Linden & Butterworth, 2014). There will be educational pamphlets that the patient will receive prior to discharge.

Pre-Discharge Education

The nurse will provide bedside education to the patient, especially on the strategies for identifying signs and symptoms of COPD exacerbation, and also preventing COPD exacerbation. Some of the presented strategies for preventing COPD exacerbation will include hand washing, flu-shots, pneumonia vaccine’s, proper nutrition, and exercise (Leader, 2014). Teaching about the benefits of the flu shot and pneumonia vaccine will be especially important as both can mitigate risk factors associated with COPD exacerbation (Leader, 2014).

According to a recent paper published in the (AJN) American Journal of Nursing, exacerbations accelerate the deterioration of lung functioning. However, many patients may only experience mild symptoms until the later stages of COPD. Therefore they will be educated on how to identify symptoms like an ongoing cough, a cough accompanied by excessive mucus, chest tightness, and shortness of breath that worsens with increased physical activity. For patients that have a history of smoking they will be advised to eliminate smoking from their daily activities and also offered cessation classes. This is because smoking accelerates the speed of lung damage.

Also, they will be advised of the risk of frequent colds and flus associated with the progression of COPD. Other associated symptoms include breathlessness with physical exertion, swollen (feet, ankles, legs), weight loss, and decreased muscle endurance. Pre-discharge education will hopefully reduce exacerbation triggers and the number of episodes and hospital visits (Healthline, 2013).

Finally the patient will be provided information and education on pollution and environmental irritants. The American Family Physician estimates that bacterial infections represent approximately 70-75 percent of COPD exacerbations while viruses represent approximately 25 percent (Healthline, 2013). Prior to discharge the patient will be provided brochures that are language appropriate and synthesize information discussed during the bedside education, by the nurse (Appendix C).

Plan for Follow-Up

In terms of follow-up care, the criteria for assessing the patient will have several components. The primary tool used for determining a patient’s condition post-discharge is a checklist (Appendix D). Within the checklist there are evidence based practices that have been previously used in previous COPD studies. Although additional questions may be added to the checklist, it provides a foundational tool for systematic evaluation. For example if the patient has indicated a history or proclivity towards smoking, then they will automatically be offered education and a cessation referral. The patient could also be referred to pulmonary rehabilitation by either the nurse practitioner or nurse with input from a respiratory therapist.

Additionally the patient will receive a COPD Self-Management book that will outline all of the triggers to exacerbation, recommendations for reducing COPD, and any other helpful information. They will also get an Oxygen alert wallet card that will for those who require one. An Oxygen alert wallet card is critical, especially for ambulance and emergency medical staff. Apposite resuscitation of hypoxic patients often requires elevated concentrations of oxygen to patients experiencing respiratory distress. However, a percentage of such patients with chronic respiratory illness will experience hypercapnia (Gooptu, Ward, Ansari, Eraut, Law, & Davison, 2006).

To mitigate such risks hospitals and local ambulances have established a systematic protocol for patients with a previous hypercapnic acidosis with a PaO2 >10.0 kPa. Such a reading would indicate that oxygen could have been detrimental to hypercapnia. Such patients are provided with an Oxygen Alert card. According to a previous study, when the Oxygen alert card was used consistently for patients with a PaO2 that exceeded 10 kPa it reduced the risk of hypercarbia. In the previous study 63 percent of patients readmitted who used the card were appropriately managed. This increased to 94 percent in incidents where ambulance and emergency were required (Gooptu, Ward, Ansari, Eraut, Law, & Davison, 2006).

Finally, there would be information provided about a breath easy group for discharged COPD patients. The breathe easy group is a support group that Palisades Medical Center can also pilot. Similar to a smoking cessation class, it would provide ongoing education and techniques for breathing techniques to help the patient better perform exercised that typically cause them to have shortness of breath. The breathe easy group will also discuss stress reduction techniques (Appendix D).

According to the World Health Organization an effective COPD management strategy must include assessing and monitoring, reduction of risk factors, maintenance of stable COPD indicators, and proper management of incidents of exacerbation. Even though the central focus of this evidence based project is pre-discharge education and limited follow-up these processes are informed by relevant health data.

For example, during hospital intake the patient is going to automatically receive testing to check airflow rates, and whether or not there is greater exposure to risk factors causing COPD. For patients with airflow limitations and elevated exposure to COPD triggers, such information will be a red flag for the nurse (World Health Organization, 2015). Subsequently even though all patients will receive the same evidence based process outlined in Appendix D, those patients with greater exposure and documented medical distress symptoms will be monitored more closely.

The goal of Self-Care is that the patient can begin to identify and report symptoms of distress. According to a recent report in instances where patients are unable to report distress symptoms they are more susceptible to being improperly treated (Campbell, 2008). Therefore a questionnaire will be established to assess the patient’s condition when they are first admitted (Appendix G). Questions will include asking the patient to describe the current condition, duration, and associated symptoms (RnCeus.com, n.d.).

In instances where a patient is unable to appropriately answer the questionnaire, or the nursing staff has inconsistent or incoherent responses then an observation scale may be utilized (Campbell, 2008). The ultimate goal is to get the subjective data directly from the patient as they are most accurately able to describe symptoms such as pain level.

In terms of an observation scale, nurses will be able to utilize tools like the Respiratory Distress Scale as a resource. While the patient is receiving hospital care the nurse will conduct periodic evaluations of the patients breathing and respiratory rates. Specific variables that will be assessed include the heart rates per minute, respiratory rate per minute, breathing patterns, and any Nasal flaring (Campbell, 2009).

If a patient has a total respiratory distress level of 5 or greater additional intervention may be required. The nurse can take data gathered from the patient questionnaire and the observation scale and use in the educational information provided to the patient pre-discharge. This will actually be more meaningful to the patient as they will have information specifically customized to their medical condition.

Feasibility of the PEDP

The anticipated cost for this program will be about $18,000, which will include at least five hours per week of the APN (Nurse Practitioner), and the nurse approximately five hours per week, and Respiratory Therapist approximately five hour per week, expenses for preparing pamphlets, printing, and a discharge document. The APN will apply for grants from the American Heart and Lung Association (2015), and the Horizon Foundation to cover the cost of the $18,000 pilot program (Bader, 2014). According to Robert Marino, CEO of Horizon Blue Cross Blue Shield of New Jersey the goal of these grants is to support Community-based organizations that are enhancing the public health and cultural vitality of the State (Bader, 2014).

Sustainability

The pilot program will be assessed at the three month (mid-point) and the six month time frame. The results will be communicated to the stakeholders (i.e. the Board) to assess the effectiveness of the program. One recommendation for implementing an Evidence-Based Practice Change is the promotion of active engagement in creating metrics and measurable outcomes ("Implementing an Evidence-Based Practice Change," 2011). This process will take place prior to the launch of the Pilot. As such, the Stakeholders will be aware of the baseline (in terms of current readmission rates for COPD patients) and current methodology.

The goal will be to establish workflow changes during the Pilot stage. If the six month pilot proves to be successful then the Board and other stakeholders can determine whether the temporary pilot program can transition to a permanent workflow. Following transition to a permanent workflow, the PDEP could eventually require policy changes. However, the Board and stakeholders would collaboratively determine the metrics and timeline for such changes to take place.

Sustainability must also consider anticipated measureable outcomes. According to a previous meta-analysis on the impact of education programs on health outcomes results were positive. The report indicated that educational programs resulted in greater understanding of Chronic Obstructive Pulmonary Disease (COPD), better disease management skills, compliance with proper inhaler use, and minimal COPD-related emergency department visits and subsequent hospital stays (Yu et. al., 2012).

Cost-Effectiveness

In terms of specific cost-effectiveness the monetized savings is directly associated with minimizing readmission rates, rates of admission to the Emergency Department, and potential costs associated with procedures for patients with exacerbated symptoms associated with COPD. However, due to the number of variables an exact cost is not yet determined. However, based on the results from a similar COPD pilot determination was made that there is a correlation between Self-Management ability, education, enhanced life of quality, and resultant reductions in hospital admissions (Paneroni et. al., 2013).

The study revealed that educational plans associated with (COPD) Chronic obstructive pulmonary disease, are effective. A formalized program enhances patient knowledge and self-management. Factors that can impact the variance of results include the specific learning instrument used and the baseline learning level of the COPD patients. Also, in the previous study there were two parts a pre-study phase and a study phase. During the pre-study phase the health team prepared for implementation and reviewed educational materials. To improve outcomes this Evidence based Project will also ensure that at least 30 days prior to the launch of the Pilot nurses go through preparation and training.

Barriers

Potential barriers include patient language, educational level, whether or not they are able to fully comprehend the information being taught. Therefore, certain individuals may be omitted from the study including those with indications of early Alzheimer’s, memory loss, or difficulty with comprehending certain basic medical instructions. Such individuals will require more specialized intervention that exists outside the scope of this PDEP evidence-based project.

There is a direct correlation between a patient’s willingness to follow the medial instructions and morbidity rates. The Center for Disease Control and Prevention (CDC) stated that among adults diagnosed with COPD only 48 percent reported daily medication use. The study indicates the need for assessment and further evaluation of the effectiveness of existent prevention and intervention programs. One recommendation is for additional education for healthcare professionals and patients regarding COPD symptoms, diagnosis, and treatment (Centers for Disease Control and Prevention, 2012). The PDEP program is designed to fill that gap and remove the current barriers.

Project Evaluation

When evaluating outcomes for evidence based projects, there are two recommended questions. The first question is did the intervention occur as planned? The second question is what was the impact of the reminiscence or evaluation process (Plastow, 2006)? Appendix E is a great resource for gathering data on patient satisfaction rates. Such information can be a critical part of any recommended modifications during the first 3 month evaluation. There will also be a Retrospective review process as outlined in (Appendix D) that will document follow-up appointments, referrals (smoking cessation, pulmonary rehabilitation), and other critical information.

All information obtained from patient surveys, pre-discharge checklists, and other data collection methodologies will be reported to stakeholders. Stakeholders will include grant funding agencies, board members, and other key persons both internally and outside of the organization.

References

American Heart Association. (2015). Aboutu our Research Program. Retrieved from https://research.americanheart.org/ris/template.jsp?pid=ris.extlogin&_requestid=67898

American Lung Association. (2014, May). Chronic Obstructive Pulmonary Disease (COPD) Fact Sheet. Retrieved from http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html

Bader, E. (2014, October 10). The Horizon Foundation awards more than $600K in grants. Retrieved from http://www.njbiz.com/article/20141010/NJBIZ01/141019983/The-Horizon-Foundation-awards-more-than-$600K-in-grants

Bieda, S., Centopanti, J., & Callaghan, N. (2012). Nursing Grand Theory. Retrieved from http://grandtheoryroyandorem.weebly.com/theory-analysis-orem.html

British Lung Foundation. (n.d.). COPD Publication for Healthcare Professionals. Retrieved from http://shop.blf.org.uk/collections/copd-hcp

Campbell, M. L. (2008). Psychometric Testing of a Respiratory Distress. JOURNAL OF PALLIATIVE MEDICINE, 11(1), 44-50. doi:10.1089/jpm.2007.0090

Campbell, M. L. (2009, February 19). Respiratory Distress Observation Scale. Retrieved from http://homecareinformation.net/handouts/hen/Respiratory_Distress_Observation_Scale.pdf

Center for Disease Control and Prevention. (n.d.). Chronic Obstructive Pulmonary Disease: COPD Among Adults in New Jersey. Retrieved from http://www.cdc.gov/copd/maps/docs/pdf/NJ_COPDFactSheet.pdf

Centers for Disease Control and Prevention. (2012, March 2). Morbidity and Mortality Weekly Report. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6108a3.htm

Fawcett, J. (2001, January). The Nurse Theorists: 21st-Century Updates-Dorothea E. Orem. «Nursing Science Quarterly, 14»(1), 34-38. doi:10.1177/08943180122108021

Feemster, L., & Au, D. (2014). Penalizing hospitals for chronic obstructive pulmonary disease readmissions. American Journal of Respiratory & Critical Care Medicine, 189(6), 634-639. doi:10.1164/rccm.201308-1541PP

Gooptu, B., Ward, L., Ansari, S. O., Eraut, C. D., Law, D., & Davison, A. G. (2006). Oxygen alert cards and controlled oxygen: preventing emergency admissions at risk of hypercapnic acidosis receiving high inspired oxygen concentrations in ambulances and A&E departments. Emerg. Med J, 23(8), 636-638. doi:10.1136/emj.2005.029991

Harrison, J., Auerbach, A., Quinn, K., Kynoch, E., & Mourad, M. (2014). Assessing the Impact of Nurse Post-Discharge Telephone Calls on 30-Day Hospital Readmission Rates. JGIM: Journal of General Internal Medicine, 29(11), 1519-1525. Doi:10.1007/s11606-014-2954-2

Healthline. (2013, October 1). Common Symptoms of Advancing COPD. Retrieved from http://www.healthline.com/health/copd/exacerbation-symptoms-and-warning-signs

Healthy People 2020 (2014). www.healthypeople.gov. Retrieved on November 19,2014 from https://www.healthypeople.gov/2020/topics-objectives/topic/respiratory-diseases

Hopkinson, N. S., Englebretsen, C., Cooley, N., Kennie, K., Lim, M., Woodcock, T., Laverty, A. A., Wilson, S., Elkin, S. L., Caneja, C., Falzon, C., Burgess, H., Bell, D., & Lai, D. (2011, August 16). Designing and implementing a COPD discharge. Chest Clinic(67), 90-92. doi:doi:10.1136/thoraxjnl-2011-200233

Implementing an Evidence-Based Practice Change. (2011, March). AJN, 111(3), , 54-60.

Leader, D. (2014, November 24). How to Prevent COPD Exacerbation. Retrieved from http://copd.about.com/od/copdexacerbation/tp/preventingcopdexacerbation.htm

Linden, A., & Butterworth, S. W. (2014, October). A Comprehensive Hospital-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial. The American Journal of Managed Care, 20(10), 783-792.

Lynes, D. (2010). Diagnosis and management of patients with COPD in primary care. Nursing Standard, 25(8), 49-57.

Matthews, H., Toole, C., Nicholls, C., & Lindsey-Halls, A. (2013). Care bundles reduce readmissions for COPD. Nursing Times, 109(7), 18-20.

Mount Carmel Health. (2011, November). Chronic Obstructive Pulmonary Disease Booklet. Retrieved from http://www.mountcarmelhealth.com/workfiles/pdf/patient_education/copd.pdf

Palisades Medical Center. (2015). Cardio Rehab Program Certification. Retrieved from http://www.palisadesmedical.org/News/144/index.html

Paneroni, M., Clini, E., Crisafulli, E., Guffanti, E., Fumagalli, A., Bernasconi, A., Cabiaglia, A., Nicolini, A., Brogi, S., Ambrosino, N., Peroni, R., Bianchi, L., & Vitacca, M. (2013, February). Feasibility and Effectiveness of an Educational Program in Italian COPD Patients Undergoing Rehabilitation. Respiratory Care (RESPIR CARE), 58(2), 327-333.

Plastow, N. A. (2006, October). Implementing evidence-based practice-a model for change. International Journal of Therapy and Rehabilitation, 13(10), 464-469.

RnCeus.com. (n.d.). Taking a Respiratory History. Retrieved from http://www.rnceus.com/resp/resphx.html

Sullivan Luallin Healthcare Consulting. (2009). Example Patient Satisfaction Survey. Retrieved from http://www.integration.samhsa.gov/pbhci-learning-community/Sample_Consumer_Satisfaction_Survey_-2of4-.pdf

Tan, J., Chen, J., Liu, X., Zhang, Q., Zhang, M., Mei, L., & Lin, R. (2012, Jul-August). A Meta-Analysis on the Impact of Disease-Specific Education Programs on Health Outcomes for Patients with Chronic Obstructive Pulmonary Disease. Geriatric Nursing (Geriatr Nurs), 33(4), 280-296.

The University of Tennessee at Chattanooga School of Nursing Faculty & Students. (2014, Fall). Theory based nursing practice. Retrieved from http://www.utc.edu/nursing/pdfs/classes/orem-handbook.pdf

World Health Organization. (2015). COPD management. Retrieved from http://www.who.int/respiratory/copd/management/en/

http://dhh.louisiana.gov/. (2011, June 26). 46 SECTION E – CHRONIC CARE/DISEASE MANAGEMENT. Retrieved from http://dhh.louisiana.gov/assets/docs/Making_Medicaid_Better/Resources/CCN_RFP_Proposals/AetnaBetterHealth/LA_CCN_RFP_Section_E_06.26.11_FINAL.pdf