About Care Transitions

Over five years ago Sun Health created Sun Health Care Transitions (SHCT), an evidence-based, in home and telephonic support program to assist patients during the critical period following an inpatient hospitalization, thus reducing the hospital readmission rate.

Shortly after its implementation, Sun Health Care Transitions was chosen by Centers for Medicare and Medicare Services (CMS) to take part in a demonstration project called Community-Based Care Transitions Program. Sun Health Care Transitions’ quickly became a national model of excellence within the program because of its stellar outcomes in reducing readmission rates which in turn has tremendous cost saving benefits.

CMS finds that approximately 17.8% of patients who are discharged from the hospital will be readmitted within the first 30 days following the initial admission.

These readmissions are often preventable and are sometimes a result of confusion over medications and how to take them; lack of education about the cause of the initial admission and awareness of what could cause a readmission; and/or lack of timely follow up with a primary care physician or specialist in the community.

The Sun Health Care Transitions team has worked hard to develop effective proprietary materials to educate patients on chronic medical conditions and diseases such as heart failure, heart attack, pneumonia, diabetes and chronic pulmonary disease, teaching valuable techniques to monitor and self-manage these conditions while also recognizing early warning signs.

Most health plans and health providers who offer care to patients following a hospital discharge focus on telephonic support to provide an initial check on the patient once at home. The Sun Health Care Transitions program utilizes a team of nurses who have home health or intensive care/critical care hospital experience and can offer both expertise and personalized education on medical conditions and medications, as well as social services support.

The initial in-home consultation, which is unique to this program, allows patients to relax with their family members by their side to listen and learn together. It also serves as an opportunity for the Sun Health Care Transitions nurse to evaluate the patient’s vital signs, review their medications and how they are organized as well as assess the home for safety.

Sun Health Care Transitions partners can feel confident knowing that our staff has adequate resources, including a social worker, registered dietitians, certified diabetes educators and memory care navigators to consult with patients if additional needs are identified.

As a participant in the program, patients become more engaged and feel confident in managing their health. This ultimately reduces healthcare utilization and future care costs while providing a higher quality of life.

The readmission rate for Sun Health Care Transitions patients average under 8% which is significantly less than national Medicare average which is around 17.8%.