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The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI
The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI
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A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program.

Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS's recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI explores the critical five pillars of the Arizona non-profit's leading care transitions management initiative, adapted from the Coleman Care Transitions Intervention®.

In this 26-page resource, Jennifer Drago, FACHE, executive vice president, population health, Sun Health, describes her organization's approach to care transitions management, which achieved the lowest readmissions rates of all programs in CMS's five-year demo.

Ms. Drago addresses the following points:

  • Business opportunities related to operating a post-acute transitions of care program;
  • The key attributes of an effective transitions of care program;
  • The essential fifth pillar Sun Health added to the Coleman four-pronged model and the impact that resulted from this modification;
  • The 'magic' of home visits as a component of care transition management;
  • Key players on the Sun Health care transition care team and their specific roles and patient interactions;
  • Program payoffs from targeting social health determinants and chronic disease;
  • Outcomes achieved with an effective transitions of care program, including metrics on Sun Health patient confidence, patient satisfaction, hospital readmissions and Medicare savings;
  • ROI potential from a transitions of care model that goes beyond savings from reduced readmissions;
  • Common myths associated with care transitions and how the Sun Health approach dispels these inaccuracies;
And much more.

Table of Contents

  • A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits
    • Introduction to Sun Health
    • Care Transitions Program Overview
    • Building on the Coleman Care Transitions Intervention®
    • 8 Elements of Sun Care Transitions Management
    • 5 Pillars of Sun Health Care Transitions
    • Home Visit Priorities
    • Patient Education
    • Medication Reconciliation
    • Social Determinants of Health
    • Patient Testimonials and Satisfaction
    • Readmission Reductions
    • System ROI
    • Dispelling 5 Myths About Care Transition Management
  • Q&A: Ask the Experts
    • Care Transition Scripting
    • Virtual Education in Lieu of Home Visits
    • Common Barriers to Successful Care Transitions
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: May 2017
Number of Pages: 26
ISBN 10: 1-943542-56-2 (Print version); 1-943542-57-0 (PDF version)
ISBN 13: 978-1-943542-56-7 (Print version); 978-1-943542-57-4 (PDF version)
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Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th, now available for replay
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