Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Mar-Apr;28(2):55-59.
doi: 10.1097/NCM.0000000000000589.

A Case Manager-Led Pneumonia Care Bundle in a Subacute Rehabilitation Facility

Deborah Granata  1   2   3 , Moira Kendra  1   2   3 , Stephanie H Chiu  1   2   3
Affiliations

A Case Manager-Led Pneumonia Care Bundle in a Subacute Rehabilitation Facility

Deborah Granata et al. Prof Case Manag. 2023 Mar-Apr.

Abstract

Purpose of the study: To evaluate the relationship between a case manager-led pneumonia care bundle at skilled nursing facilities (SNFs) and 30-day hospital readmissions for pneumonia.

Primary practice settings: The primary practice settings included patients hospitalized with pneumonia at 2 community hospitals between October 2018 and June 2019 and who were subsequently transferred to an SNF.

Methodology and sample: A retrospective cohort study was completed comparing patients in the preintervention cohort who received pneumonia standard of care versus patients in the postintervention cohort who received a case manager-led evidence-based pneumonia care bundle at an SNF. From October 2018 to June 2019, patients admitted with pneumonia to 2 community hospitals in Northwest New Jersey were enrolled in the preintervention cohort. Patients admitted with pneumonia from January 2020 to June 2021 were enrolled in the postintervention group. The primary outcome was to reduce 30-day readmission rates for all patients discharged from the hospital to an SNF with pneumonia.

Results: Ninety-nine patients were enrolled in the preintervention cohort and 34 patients were enrolled in the postinterventions cohort. Thirty-day readmission rates were lower in the postintervention cohort (24.2% vs. 17.7%). This reduction in readmission rates was clinically significant, demonstrating a 27% reduction for all patients discharged from the hospital to an SNF with pneumonia.

Implications for case management practice: Individualized pneumonia self-management education can be easily implemented in SNFs to improve quality-of-care outcomes for patients. Our health care system collaborates with several SNFs to decrease 30-day hospital readmission. The pneumonia care bundle includes specific measures to improve the transition of care for patients with pneumonia by decreasing the variability of patient care after discharge from the hospital to an SNF. It was hypothesized that to decrease readmissions from the SNFs, we needed to address the quality of care provided by the SNFs by using a 2-prong approach; education of SNF staff on the pneumonia care bundle, and in-person weekly follow-up visits in the SNF until discharge from the SNF to the patient's home.

PubMed Disclaimer

Conflict of interest statement

The authors report no conflicts of interest.

References

    1. Adamuz J., Viasus D., Simonetti A., Jiménez-Martínez E., Molero L., González-Samartino M., Castillo E., Juvé-Udina M.-E., Alcocer M.-J., Hernández C., Buera M.-P., Roel A., Abad E., Zabalegui A., Ricart P., Gonzalez A., Isla P., Dorca J., Garcia-Vidal C., Carratalà J. (2015). Impact of an educational program to reduce healthcare resources in community-acquired pneumonia: The EDUCAP randomized controlled trial. PLoS One, 10(10), e0140202. https://doi.org/10.1371/journal.pone.0140202 - DOI
    1. Borzecki A. M., Chen Q., Restuccia J., Mull H. J., Shwartz M., Gupta K., Hanchate A., Strymish J., Rosen A. (2015). Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems? A cross-sectional observational study. BMJ Quality & Safety, 24(12), 753–763. https://doi.org/10.1136/bmjqs-2014-003911 - DOI
    1. Hadfield J., Bennett L. (2018). Determining best outcomes from community acquired pneumonia and how to achieve them. Respirology, 23(2), 138–147. https://doi.org/10.1111/resp.13218 - DOI
    1. Hatipoğlu U., Wells B. J., Chagin K., Joshi D., Milinovich A., Rothberg M. B. (2018). Predicting 30-day all-cause readmission risk for subjects admitted with pneumonia at the point of care. Respiratory Care, 63(1), 43–49. https://doi.org/10.4187/respcare.05719 - DOI
    1. Hayes B., Haberling D., Kennedy J., Varma J., Fry A., Vora N. (2018). Burden of pneumonia-associated hospitalization: United States, 2001-2014. Chest, 153(2), 427–437. https://doi.org/10.1016/j.chest.2017.09.041 - DOI

LinkOut - more resources