Touting 'Magic' of Home Visits, Sun Health
Dispels 5 Care Transition Management Myths
With an average of 299 warm, sunny days a year, Phoenix is a mecca for senior transplants. However, as Phoenix-based Sun Health knows well, when an aging population relocates far from their adult children, there's a danger that if some of them experience cognitive decline or other health issues, no one will notice.
That's one reason home visits are the cornerstone of Sun Health's Care Transitions Management program. Visiting recently discharged patients at home not only tracks the individual's progress with the hospitalization-related condition, but also pinpoints any social determinants of health (SDOH) that inhibit optimum health.
"There are a number of social determinants of health that, if not addressed, could adversely impact the medical issue," explains Jennifer Drago, FACHE, executive vice president of population health for the Arizona non-profit organization. Ms. Drago outlined the program during A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar available for replay.
In case you missed this webinar, you still have a chance to watch this highly-rated program.
Register to view the conference today or order your training DVD or CD:
Identifying SDOH such as medication affordability, transportation, health literacy and social isolation are so important to Sun Health that SDOHs form the critical fifth pillar of its Care Transitions Program. Modeled on the Coleman Care Transitions Intervention®, SDOH identification and support balance Coleman's four pillars of education, medication reconciliation, physician follow-up visits, and personalized plan of care.
The belief that organizations can effectively execute transitions of care programs pre-discharge or by phone only is one of five care transition myths Ms. Drago dispelled during the webinar. "You will have an impact [with phone calls], but it won't be as great as a program incorporating dedicated staff and that home visit. I can't tell you the magic that happens in a home visit."
That "magic" contributed to Sun Health's stellar performance in CMS's recently concluded Community-Based Care Transitions Program demonstration. Sun Health was the national demo's top performer, achieving a 56 percent reduction in Medicare 30-day readmissions—from 17.8 percent to 7.81 percent—as compared to the 14.5 percent readmission rate of other demonstration participants.
Sun Health's multi-stepped intervention begins with a visit to the patient's hospital bedside. "Patients are a captive audience while in the hospital," explained Ms. Drago. That scripted bedside encounter, which boosted patients' receptivity to the program, addresses not only the reason for the hospitalization (hip replacement, for example) but also co-occuring chronic conditions, she continued.
"The thing that will have the greatest chance of going out of whack or out of sync in their recovery period is their chronic disease, because they're probably not eating the same, they're more sedentary, and their medications likely have been disrupted."
Ms. Drago went on to present some of the intervention's tools, including care plans, daily patient check-ins, and the science behind her organization's care transitions scripts.
After sharing six key lessons learned from care transitions management, Ms. Drago noted that while her organization participated as a mission-based endeavor, others could model Sun Health's intervention and benefit from those readmissions savings.
You can "attend" this program right in your office and learn more about Sun Health's care transition program. It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear details about how Sun Health: uses scripting within the care transitions to increase program retention rates; provides virtual education for patients in lieu of a home visit; and addresses barriers to care, including transportation, medication affordability and other common barriers.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, please visit:
P.S. -- You may also be interested in these care transition resources: