Sun Health Care Transitions Program

Representatives from the Lewin Group, a health care consulting firm working for the Centers for Medicare & Medicaid Services (CMS), visited Sun Health in June to learn what the Care Transitions team is doing to help Medicare beneficiaries make a smooth transition from hospital to home and to keep from being readmitted.

Studies show that 18-20% of Medicare
patients discharged from a hospital – approximately 2.6 million seniors – are readmitted within 30 days at a cost of over $26 billion every year. In contrast, Sun Health’s Care Transitions Program has been able to dramatically reduce hospital readmissions an average of 7% for its enrolled patients.

In May 2013, the Sun Health Care Transitions program became one of 100 nationwide demonstration sites participating in the Community-Based Care Transitions Program. CCTP sites use an evidence-based model to reduce readmissions, and improve quality and outcomes when patients transition from hospitals to their homes or other care settings, and to achieve measurable savings for the Medicare program. The Lewin Group provides technical assistance and guidance for CCTP programs, gathering best practices through site visits and facilitating peer to peer information sharing through online collaboration and national meetings.

Sun Health partners with Banner Boswell Medical Center and Banner Del E. Webb Medical Center to enroll high-risk Medicare beneficiaries in the program. The 30-day program includes an in-home nursing assessment, chronic disease education, medication review and education, home safety evaluation, fall risk assessment, and weekly follow-up calls.

There is no cost to patients for the program. It is funded through grants and contributions from Sun Health Foundation.

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