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Sun Health, an Arizona non-profit organization, launched its Sun Health Care Transitions program in November 2011. Modeled after the Coleman Care Transitions Intervention® and adapted to meet the needs of its community, the program has been credited with keeping readmission rates well below the national average.
Sun Health's program was part of the Center for Medicare and Medicaid Services' National Demonstration Program, Community-Based Care Transitions Program, which ended in January. Not only did Sun Health lead the CMS demonstration project with the lowest readmission rates, Sun Health also widened the gap between their expected 30-day readmission rate (56 percent lower than expected) and their expected 90-day readmission rate (60 percent less than expected).
During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 23, 2017 webinar, now available for replay, Jennifer Drago, FACHE, executive vice president, population health, Sun Health, shares the key features of the care transitions program, along with the critical, unique elements that lead to its success.
You will learn:
- How Sun Health adapted the Coleman Care Transitions Intervention® to meet the needs of its community;
- The key roles of the care transition care team, which include a registered nurse, a licensed practical nurse and a social worker, and how and when they interact with the patient;
- How addressing social health determinants and applying a chronic disease focus within the program improved results;
- How Sun Health links to existing services in its community for aging in place to help address barriers to care plan adherence; and
- Sun Health's approach to sustaining the program now that the CMS Community-Based Care Transitions Program demonstration project has ended.
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WHO WILL BENEFIT FROM THIS CONFERENCE?
Presidents & CEOs, medical directors, quality improvement executives, physician executives, performance improvement professionals, case and care management executives, and strategic planning directors and consultants.
ABOUT OUR PANELIST:
Jennifer Drago, FACHE, MHSA, MBA, is the Executive Vice President of Population Health for Sun Health, where her role is to identify community health needs and to develop and operate services to meet these needs.
Drago has launched seven new community health programs in the past five years, including an innovative chronic disease/wellness program, a nationally-recognized transitions of care program, and a continuing care at home program that is the first of its kind in Arizona. She also helped to form a new community nonprofit to focus on senior transportation.
Drago has 23 years of healthcare experience including work in planning, operations and policy. She is a Fellow of the American College of Healthcare Executives. She earned a bachelor's degree in finance, an MBA and a master's in health services administration from Arizona State University.