WBB's Thought Leadership

Care Transitions

August 17

Sun Health Care Transitions (SHCT) launched a transitional care program that reduced readmission rates by 57% among patients 65 or older. The program yielded an estimated savings of $17.3 million.

WBB Take:
Care transitions are a high-risk stage in the overall patient journey, and suboptimal transitions can lead to high 30-day readmission rates. The current statistics show that patients aged 65 and older are the most likely to be re-hospitalized within 30 days of being discharged from inpatient care.
High readmission rates result in waste, and consume valuable resources on preventable situations. To lower costs and conserve resources healthcare organizations need to begin implementing discharge programs that include specific medication, self-care, and follow-up instructions. Before the patient leaves, processes need to be in place to ensure that the patient or the receiving care provider has a complete understanding of the follow-up care needed.
Programs such as Sun Health Care Transitions (SHCT) show the significant benefits of easy to implement processes that will improve patient outcomes post-discharge, lower costs of care, enhance quality of life, and prevent hospital readmissions. It is important that healthcare providers allow enough time with patients to allow them to ask questions and gain full understanding. Having the patient or care provider repeat back the information to ensure understanding is one tactic that could be utilized.


Cited by Stephanie Owusu, Julia Davis, and Matthew Loxton


Excerpt: “Nearly one-fifth of elderly patients discharged from inpatient care are re-hospitalized within 30 days, costing Medicare $17.4 billion annually. Transitioning from one care setting (typically the hospital) to another (typically home) can be a confusing time for patients and caregivers, particularly among those aged 65 or older. The often-hasty transition process can lead to quality and safety problems contributing to sub-optimal patient outcomes and hospital readmissions. Patients often do not have a good understanding of their medication instructions, self-care techniques, how to identify symptoms to report, or the importance of timely follow-up with their healthcare provider.”

“Transitional care interventions have shown success in preventing recurring and avoidable readmissions of chronically ill or at-risk adults after a hospital discharge by utilizing home visits, encouraging timely visits to healthcare providers, promoting chronic-disease self-management, and encouraging more collaboration between disciplines. Interventions often include well-trained healthcare providers educating patients and their families on how to identify common problems that may arise during and following transitions in care.”
“In 2011, Sun Health, a nonprofit based in Surprise, AZ, launched a transitional care intervention program aimed at improving patient outcomes post-discharge, lowering costs of care, enhancing quality of life, and preventing hospital readmissions.”

“The program, Sun Health Care Transitions (SHCT), joined a federally funded demonstration project in 2013. Sun Health’s program recorded the lowest 30-day readmission rates of all participants in the recently concluded Community-based Care Transitions Program, overseen by CMS.”
“Registered and licensed practical nurses served as “transition coaches,” based on the belief that nurses are better equipped than other healthcare providers to help patients understand their illness, teach them how to better manage their own care, and connect them to community-based services to help manage their health.”
“Since its inception, Sun Health has reduced 30-day readmissions by 57% from what would have been expected according to the national average of about 18%, achieving a readmission rate of less than 8% (Figure). The reductions in readmission led to an estimated savings of $17.3 million since inception of SHCT, based on Medicare’s actual cost of readmission of $12.8 million compared to an expected $30.1 million.”

Source: Physician's Weekly


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