PURPOSE: To compare the hospital readmission rates for patients with COPD who require supplemental oxygen therapy following discharge from a COPD exacerbation who are entered into a home-care based, respiratory therapist centered transition of care program versus usual care.
METHODS: Patients with a COPD exacerbation who required supplemental oxygen therapy on hospital discharge were prospectively enrolled into a post hospitalization transition of care program [Discharge, Assessment and Summary @ Home (D.A.S.H., Klingensmith HealthCare, Ford City , PA)]. The program consists of face to face visits by a respiratory therapist with the patient in their home on days 1, 7, and 30 following hospital discharge. The visits are supplemented by 12 care coordinator phone interviews. Education, behavior modification, skills training, oxygen titration during performance of activities of daily living, clinical assessment, and adherence data collection are components of the program. The 30 readmission rates following discharge for all patients entered into the program over a nine month period (March 2010 through January 2011) were evaluated.
RESULTS: 229 consecutive patients with COPD (mean age 72 + 11 years) from 23 different hospitals were enrolled into the program. 40 (17%) patients refused continuing in the program after the first home visit. The 30 day readmission rate for those patients who chose to continue the program (189/229) was 3% while the 30 day readmission rate for those patients who refused to continue the program (40/229) was 13%.
CONCLUSIONS: A respiratory therapist based patient centered management program resulted in a decrease in the 30 day readmission rates for those patients who elected to continue with that management program.
CLINICAL IMPLICATIONS: Adherence to any therapeutic regimen is a vital component of care. For those patients who failed to continue in the transition of care program there was a higher 30 day readmission rate. Further investigation into the reasons for lack of willingness to continue enrollment in this program should be undertaken.
DISCLOSURE: Kim Wiles: Employee: Klingensmith HealthCare employee
Dan Easley: Employee: Klingensmith HealthCare employee
The following authors have nothing to disclose: Brian Carlin, Nan Rees
No Product/Research Disclosure Information