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June 13, 2017

This nurse-led approach cut hospital readmission rates by 56 percent

Daily Briefing

Editor's note: This popular story from the Daily Briefing's archives was republished on June 19th, 2019.

A small tweak helped community health not-for-profit Sun Health cut the Medicare 30-day hospital readmission rate for program participants by 56 percent—and achieve the lowest readmissions rate among all participants in CMS' Community-based Care Transitions Program.

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About the Community-based Care Transitions Program

According to AHA News, CMS launched the CCTP program to discover new ways of curbing hospital readmissions, cutting Medicare costs, and improving care quality. Under the program, hospitals partner with community agencies to help patients foster skills and access resources they need to avoid readmissions. The lead organizations involved in the initiative received an all-inclusive rate for caring for patients for 180 days after discharge from the hospital, AHA News reports.

Sun Health, located in Sunrise, Arizona, was one of 18 locations across the United States to complete the program, according to AHA News. The organization collaborated with Banner Boswell Medical Center in Sun City and Banner Del. E Webb Medical Center in Sun City West, and about 12,000 patients participated in Sun Health's initiative.

According to AHA News, all of the health care organizations participating in the demonstration project implemented programs that featured a personal health record, medication reconciliation, and timely follow-up care with a provider, as well as education about the progress of certain chronic diseases, warning signs of a worsening condition, and strategies on how to address such instances.

A different path

But Sun Health customized its implementation of the program to better serve patients, and according to Sun Health staff, that's what set the model apart. "We looked at the social determinants of health, such as medication affordability, transportation, health literacy, and social isolation—and linked people to resources in the community from which they might benefit," said Jennifer Drago, EVP of population health for Sun Health.

And while most of the programs in the demonstration project had social workers follow up with patients after discharge, Sun Health instead relied on nurses to serve as "transition coaches." Under the program, a patient would meet with a licensed practical nurse while in the hospital, receive a call from that nurse before discharge, and would receive a visit at home by an RN. The RN while at the patient's home educates the patient, assesses medications, and conducts a patient assessment, including an evaluation of the patient's risk for depression or falls.

Depending on the health literacy and condition of the patient, the RN also teaches the patient how to answer his or her own medical questions, and if the RN encounters a critical condition, he or she arranges a call with the patient's doctor while the patient is on the line. In addition, the program makes social workers available for patients who need additional support.

According to Deb Richards, director of care transitions at Sun Health, that the decision to rely on nurses "was a big part of our success." She explained, "We felt strongly that it should be a nurse who goes into the home. For patients who are struggling with their disease, it helps to have a nurse who can help them understand what is going on and make sure that some of those social determinants don't occur."

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Overall, the readmission rate for program participants fell from 17.8 percent to 7.8 percent, AHA News reports.

Moreover, 99 percent of patients in the program said they would recommend it to others, and that they felt more confident about managing their own health conditions after completing the 30-day program, according to a survey Sun Health recently conducted. "This is not just about preventing readmissions," said Drago. "We have improved peoples' lives."

And for programs hoping to have similar success, Drago recommends they "start with an evidence-based program." She said, "You don't need to re-invent the wheel, but have a long-term strategy for what you want your intervention to look like. And don't discount the value of home visits and the magic that comes from that one-on-one work with the patient" (AHA News, 6/6).

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