Care Transition Program and Patient Education Leads to Reduction in Readmission Rates in Patients Discharged With COPD and Pneumonia

Background: In 2016 the average 30-day readmission rate for COPD and Pneumonia (PNA) at Sutter Roseville Medical Center (SRMC) was 15. 4% and 12.2% respectively. In an effort to improve quality of care and reduce readmission rates at SRMC a Care Transition Coordinator (CTC) program was created. This program is intended to accurately identify appropriate patients in need of intensive transition planning and support and partnership with Pulmonary Medical Associates (PMA) to provide Transitional Care Management (TCM) services to patients after discharge from the hospital. Methods: Patients admitted for COPD or PNA are identified within 24 hours allowing for timely interactions, risk stratification, and transition planning. Daily communication occurs via email, plus rounding with multidisciplinary team. Timely documentation occurs and is accessible to all team members. Patients are provided education on symptom management, signs of recurrent illness and are encouraged to contact their PCPs at the first signs of illness. Those eligible for TCM follow-up are provided information and appointments are scheduled prior to discharge. Patients are contacted within 48 h of discharge by a nurse practitioner. Recommendations are given for services prior to discharge based on needs assessment including exercise oximetry, rehab evaluation, consults with speech therapy, palliative care, and social work in addition to pulmonology consults. Resources and education provided include Stoplight tools for symptom recognition, medication review, COPD Assessment Test (CAT) to classify disease severity, assessment of patient symptoms and FEV1/FVC to assign GOLD Guideline Grade, referral to PR for qualifying patients and PNA kit (thermometer, oral, and hand hygiene supplies). Results: The outcome at SRMC was a reduction in 30-day readmissions for COPD from 15. 4% in 2016 to 12.4% in 2017. This rate has continued to drop to an average of 8% in the 1st quarter of 2018. PNA 30 day readmissions have decreased from 12.2% in 2016 to 9% in 2017 and continues to be at 9% in the first quarter of 2018. Conclusions: The CTC program at SRMC has reduced 30-day readmission rates for people admitted with COPD or PNA. This has happened through supplying greater resources to assess patient needs in transitioning out of the hospital. Education is provided to patients, families, and caregivers in an effort to increase compliance with medications, symptom management and recognition of when to seek medical care.