Transitional Case Management: A Method for Establishing Self-Advocacy and Reducing Hospital Readmissions in COPD Patients

Abstract

Patients with chronic obstructive pulmonary disease (COPD) present challenges to the nursing profession. These patients have a high demand for education regarding the management of medications and other aspects of care. A review of the literature shows that a reproducibly effective method for managing these patients outside the hospital setting has not yet been established, and a high percentage of these patients are commonly discharged from the hospital and then quickly readmitted for COPDrelated diagnoses. Good Samaritan Hospital has recently started using a program commonly referred to as transitional case management.This program involves visiting patients initially in the hospital, and then at home, to teach them how to manage their medications, establish a personal health record, and recognize early symptoms of illness so that proper treatment may prevent acute illness. The program is unique in that it assesses a patient’s ability to demonstrate self-management of his or her disease.