A multidisciplinary group will be organized to be led by nurse practitioners (NPs). An office will be established in the target site that will be responsible in handling all the communications, conferences, records and other business related issues. Community partnership will be initiated with the local hospitals, medical clinics, laboratories, pharmacies, and other establishments/ organizations that would make possible impact with the goals and objectives of the study. Patients’ referral sources will be the hospitals, medical clinics, board and care, assisted living facilities and other establishments/organizations in the target site. For the purpose of this study, there will be patient’s selection process. Initial screening will be done in the office according to the general information received from the referral source. The evaluating nurse will do the final screening at the patient’s home. A data gathering tool previously designed will be used that will be the basis of patient’s selection for the inclusion in the study and also the basis for the plan of care. The evaluating nurse will communicate with the NP for the initial order before leaving the patient’s home and would involve the patient or the responsible party in formulating the initial plan of care. Interdisciplinary conferences would follow the patient’s admission to the program that will tackle modifications in the initial plan of care if needed and other related issues. Periodic review of the study design will be conducted routinely during interdisciplinary conferences. This will ensure the quality of service and adherence to the study design. Composite of the multidisciplinary group are the NPs, skilled nurse, social worker, dietitian, physical therapist, occupational therapist, speech therapist and volunteers. Each will have distinct functions related to their field of specialty. Ethical and legal issues relating to this study will be addressed accordingly. Consent and permits to enroll prospective patients in the program will be prepared and utilized. Patients will be appropriately informed of their rights and responsibilities. HIPAA and privacy will be observed. Monitoring tools will be created and these will reflect patients’ clinical course while in the program. The program will entail direct patient care at home and that includes skilled observation and assessment, monitoring, health teachings and medication management among others. Referral to other health care agencies will be considered as deemed necessary. Every health care provider and patient interaction will be properly documented. Each participant of the program will be covered with a patient’s chart.
Inclusion criteria for the study are: African-American, hypertensive, diabetic, obese, smoker, and physically inactive. Target site must be an underserved area