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Rehospitalization Rates and Clinical Characteristics of Patients Enrolled in a Transition of Care Plan Following Hospitalization for Pneumonia FREE TO VIEW

Brian Carlin*, MD; Dan Easley, BS; Kim Wiles, RRT
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Drexel University School of Medicine, Pittsburgh, PA

Chest. 2012;142(4_MeetingAbstracts):139A. doi:10.1378/chest.1390614
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SESSION TYPE: Pneumonia Morbidity and Mortality

PRESENTED ON: Sunday, October 21, 2012 at 01:15 PM - 02:45 PM

PURPOSE: To evaluate the outcomes of a home-care based, respiratory therapist centered transition of care program on rehospitalization rates for patients hospitalized with pneumonia who require supplemental oxygen on hospital discharge. To evaluate the clinical characteristics of these patients.

METHODS: Patients with pneumonia who required supplemental oxygen therapy on hospital discharge were entered 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 on days 2, 7, and 30 following hospital discharge. The visits are supplemented by a series of 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 day readmission rates following discharge for all patients entered into the program over a two year period (March 2010 through March 2012) were evaluated.

RESULTS: 22 consecutive patients with pneumonia (mean age 72 + 13 years, range 56-98 years) from 23 different hospitals were enrolled into the program. All required supplemental oxygen use on hospital discharge. Nine (41%) patients completed the 30 day program, 3 (13.6%) discontinued at the end of week 1, 5 (22.7%) discontinued after the initial visit, and 5(22.7%) refused entry into the program. The 30 day readmission rate for the group of 22 was 0 (0%). The mean Borg score for dyspnea was 1.34 (range 0-8). No patients were entered into a rehabilitation program during the month. Seven were entered into a home health program (4 who entered the program and 3 who refused program entry).

CONCLUSIONS: The use of this patient centered management program resulted in a decrease in the 30 day readmission rates (compared to historical controls) for those patients with pneumonia who required supplemental oxygen therapy.

CLINICAL IMPLICATIONS: Transition of care programs can help to reduce the rehospitalization rates for patients who have pneumonia. Further research into the clinical characteristics of such patients is necessary.

DISCLOSURE: Dan Easley: Employee: Klingensmith HealthCare

Kim Wiles: Employee: Klingensmith HealthCare

The following authors have nothing to disclose: Brian Carlin

No Product/Research Disclosure Information

Drexel University School of Medicine, Pittsburgh, PA




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