Sun Health in Surprise, Ariz., knows what it takes to prevent Medicare patients from returning to the hospital within 30 days of discharge.

The health care organization had the lowest 30-day readmission rates of all participants in a recently concluded five-year federally funded demonstration project.

Its Care Transitions Management program achieved a 56% reduction in Medicare 30-day readmissions – from 17.8% to 7.8% – compared to the national average of 18%.

Nurses visiting recently discharged elderly patients at home and connecting them, as needed, to community-based services to help manage their chronic disease had a big part to do with its success, Sun Health officials says. 

The initiative was part of the Centers for Medicare & Medicaid Services’ (CMS) Community-based Care Transitions Program that enlisted community agencies to work with hospitals to help patients build skills and resources to prevent repeat hospital visits. Sun Health’s initiative was one of 18 sites across the country to complete the program.

CMS launched the demonstration to find ways of reducing hospital readmissions, improve patients’ care and lower costs for Medicare. The project’s lead organizations were paid an all-inclusive rate for serving patients during a 180-day post-discharge period. Sun Health partnered with Banner Boswell Medical Center in Sun City and Banner Del E. Webb Medical Center in Sun City West to enroll some 12,000 patients in the project.  

The demonstration’s participants implemented programs that included a personal health record; medication reconciliation; prompt follow-up with a physician; and education about the disease process, warning signs of an exacerbation and how to respond.

But Sun Health modified the model to better serve its population. “Our model might have set our results apart from other participants,” says Jennifer Drago, Sun Health’s executive vice president of population health. “We looked at the social determinants of health, such as medication affordability, transportation, health literacy and social isolation – and linked people to resources in the community from which they might benefit.”

Most projects relied on social workers to follow up with patient at home. But Sun Health used nurses as its “transition coaches.”

“We think that was a big part of our success,” says Deb Richards, Sun Health’s care transitions director. “We felt strongly that it should be a nurse who goes into the home. For patients who are struggling with their disease, it helps to have a nurse who can help them understand what is going on and make sure that some of those social determinants don’t occur.”

Under the care transition program, a licensed practical nurse meets the patient in the hospital and calls the patient before discharge as a follow up to a registered nurse’s (RN) home visit. The RN teaches, reviews medications and completes a patient assessment, including an evaluation of the person’s fall risk and a mini-depression screening.

Depending on the person’s health literacy and urgency, the nurse may instruct the patient on how to find the answer to a question about a medical issue. If critical, the nurse will call the physician, with the patient on the line, for resolution. Social workers also are available to help patients who need more support.

“This is not just about preventing readmissions,” Drago says. “We have improved peoples’ lives.”

Sun Health launched its care transitions management program in 2011. It recently conducted a survey that showed nearly 99% of patients would recommend the program to others. Results also found that patients became more confident that they could manage their health conditions during and after the 30-day program.

Drago’s advice for other health care organizations looking to replicate Sun Health’s efforts: “Start with an evidence-based program. You don’t need to re-invent the wheel, but have a long-term strategy for what you want your intervention to look like. And don’t discount the value of home visits and the magic that comes from that one-on-one work with the patient.” 


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