Cardiovascular Disease |

Rehospitalization Rates and Clinical Characteristics of Patients Enrolled in a Transition of Care Program Following Hospitalization for Congestive Heart Failure FREE TO VIEW

Brian Carlin*, MD; Kim Wiles, RRT; Dan Easley, BS
Author and Funding Information

Drexel University School of Medicine, Pittsburgh, PA

Chest. 2012;142(4_MeetingAbstracts):114A. doi:10.1378/chest.1390687
Text Size: A A A
Published online


SESSION TYPE: Heart Failure Posters

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 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 CHF who require supplemental oxygen following hospital discharge. To evaluate the clinical characteristics of the patients enrolled in the program.

METHODS: Patients with CHF 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)]. All patients were receiving supplemental oxygen therapy on discharge. 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: 24 consecutive patients with CHF from 23 different hospitals were enrolled into the program and completed the thirty day program. The thirty day readmission rate (all cause) for this group was 0 (0%). Twelve (50%) had a Borg scale score for dyspnea greater than 3. Eleven (46%) of the 24 did not have a followup physician/primary care provider visit during the 30 day period. Two (8%) were entered into a rehabilitation program. Twenty two (91%) remembered receiving the influenza vaccine and seventeen (71%) remembered receiving the pneumococcal vaccine.

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 CHF who required supplemental oxygen therapy. Followup physician visits and entry into rehabilitation are provided in less than half of the instances following discharge.

CLINICAL IMPLICATIONS: A patient centered transition of care program can be succesfully used to help reduce the 30 day readmission rates for patients following hospitalization for an exacerbation of their underlying CHF.

DISCLOSURE: Kim Wiles: Employee: Klingensmith HealthCare

Dan Easley: Employee: Klingensmith HealthCare

The following authors have nothing to disclose: Brian Carlin

No Product/Research Disclosure Information

Drexel University School of Medicine, Pittsburgh, PA




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543