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Chronic obstructive pulmonary disease (COPD) remains a significant cause for hospitalization and with complex management issues upon discharge a significant portion are being re-admitted within 30-days of first hospitalization. The beneficial effects of pulmonary rehabilitation (PR) in the management of COPD is well documented but continues to be underutilized as an important management strategy to reduce hospital readmissions. Transitional care programs which include nurse coaches, have immerged to empower patients to manage their disease and facilitate transitions through multiple care environments. Little is known about the efficacy of such programs on referral and participation in PR and subsequent reductions in readmissions. The aim of this study was to compare receipt of referral and participation in PR and 30-day readmission rates in patients with COPD who received a transitional care program (CTI) with those who received a routine hospital discharge plan. The CTI included medication reconciliation and nurse coach visits in-hospital and in the home. Data was collected retrospectively from electronic health records and included 215 subjects (Mean age 71, 45% female), with 54 enrolled in the intervention group. Results indicate subjects who received a CTI demonstrated higher rates of PR participation (22%; 4%; p=0.001) and received a greater number of referrals (57%; 14%, p=.007). There were no significant differences related to 30-day hospital readmissions (24%; 14%, p=.089) however subjects who participated in PR were less likely to experience an early readmission. Coordinated, interdisciplinary hospital initiated transitional care programs, which include a nurse coach, may facilitate PR referral and empower patients to attend PR.


Thematic Poster presented at American Thoracic Society 2017 International Conference, Washington, D.C., 2017.