Improving transitions of care in COPD patients
Date
2021
Authors
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Journal ISSN
Volume Title
Publisher
University of Delaware
Abstract
Introduction/Background: Improving the delivery of transitions of care among the COPD patient population to reduce readmission rates and poor patient outcomes is needed. COPD related hospitalizations are a significant problem within the nation’s health care system and can be attributed to a high rate of mortality. Hospital readmissions can contribute to adverse patient outcomes such as hospital acquired infections that can increase costs and deem the hospital ineligible for Centers for Medicare and Medicaid Service (CMS) reimbursement. Transitions of care among the chronically ll should be standardized with thoughtful implementation and should include a formal handoff process. ☐ Statement of the Problem: Excessive COPD readmissions are associated with financial penalty from CMS. The standard of care for patients being discharged from acute care to home care, does not include a formal standardized Registered Nurse (RN) handoff process to the home care nurse. In order to reduce the readmission rate and improve patient outcomes, implementation of an effective RN to RN handoff utilizing the DATAS form for smooth, safe transitions in care within the COPD patient population discharged to home with home care has been proposed. Methods: Methods included producing a handoff form from an acute setting for COPD patients being discharged to home with home health nursing services. Participants were COPD patients admitted to a pulmonary step-down unit identified by a COPD diagnosis code during a chart review. Methods included collaboration with health care team members and a chart review to complete the handoff form to share with the home health care agency and home health nurse in the patient’s home residence. Data collected includes the discharge date and sequential readmission dates after August 24, 2020 during the 90-day pilot. ☐ Outcomes: Results revealed the overall hospital readmission rate during the three months of August through November 2020 for each respective month was 50%, 50%, and 0%, compared to the COPD pilot readmission rate of 40%, 42%, and 0%. ☐ Implications for Practice: This COPD pilot has findings that encourage hospital leadership to develop effective strategies aimed at improving transitions of care among COPD patients to reduce readmission rates and improve hospital operating costs ultimately increasing hospital revenue. The observations noted in the COPD pilot supports the cumulative impact of standardization of transitions of care utilizing a handoff form within the acute care setting to home health care to provide improvements in patient outcomes among high-risk patient populations.
Description
Keywords
Acute care transitions, Home health, Chronic obstructive pulmonary disease, Hospital readmissions, Handoff form