SURPRISE, ARIZ. – Aug. 26, 2015 – At age 98, Lester Dray has the energy and keen mind of someone half his age. By many measures, he’s in excellent health but his chronic obstructive pulmonary disease (COPD) acts up occasionally as it did recently, which landed him in the hospital for four days, followed by a 12-day stay in a health and rehabilitation center.
He’s back home now and received a visit from registered nurse Linda Esparza who checked Dray’s blood pressure, listened to his lungs and reviewed his medications. She spent most of her visit educating Dray about COPD and answering his questions.
“I’m an inquisitive type so I ask a lot of questions,” the retired Shell Oil executive said. “It’s always useful to talk to someone who has clinical expertise and Linda answered all my questions.”
Esparza works for Sun Health’s Care Transitions program, a Centers for Medicare and Medicaid (CMS)-funded demonstration project aimed at reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.
Studies show that almost 18 percent of Medicare patients discharged from U.S. hospitals — over two million seniors — are readmitted within 30 days at a cost of over $26 billion every year. Sun Health’s Care Transitions Program (SHCTP) has been able to buck that trend, reducing hospital readmissions for its enrolled Medicare patients to an average of 8.5 percent, based on CMS data from May 2013 to present.*
On the strength of this and other outcomes, CMS recently extended Sun Health’s contract and increased its enrollment from a monthly average of 150 enrollees to 270 enrollees, an 80 percent increase.
“Part of the increase reflects the fact that we have had good outcomes in terms of meeting enrollment targets and reducing readmissions,” said Jennifer Drago, Sun Health executive vice president of Population Health. “It also reflects CMS’s desire for CCTP programs to reach more of the Medicare fee-for-service (FFS) population in their partner hospitals.”
Nationally, Sun Health’s program is one of just 46 demonstration sites still participating in the Community-based Care Transitions Program (CCTP). Launched by CMS in 2012, the CCTP originally included 102 sites, but sites that failed to meet enrollment and readmission reduction targets were not extended.
The CCTP targets Medicare FFS beneficiaries living independently who have a hospital admission and one or more chronic health conditions — 
such as heart failure, COPD, heart disease or diabetes. Sun Health, which became a demonstration project site in 2013, partners with Banner Boswell Medical Center and Banner Del E. Webb Medical Center to enroll patients in the program.
Sun Health’s Care Transitions is a 30-day program that includes a nursing assessment, chronic disease education, medication review and education, a home-safety evaluation, a fall-risk assessment and information on community resources, all provided during an in-home visit by a registered nurse within 48 to 72 hours after the patient has been discharged. Licensed practical nurses make weekly follow-up calls to check on the patient, reinforce education and confirm that doctor appointments have been made and kept. A social worker is available to assist patients who need extra support.
There is no cost to patients for the program. It is funded through a combination of CMS demonstration project funding and contributions from Sun Health Foundation donors.
Recent data show that existing CCTPs, as a group, have lowered their readmission rates to 15 percent; better than the almost 18 percent readmission rate of all U.S. hospitals, but paling in comparison to Sun Health’s rate of 8.5 percent.
Drago cites three main factors for the program’s success. “We take extra care selecting and training our staff; we use evidence-based practices to teach patients how to manage their chronic health conditions; and if there’s a need, we address patient’s social issues, connecting them to community resources,” she said. “It’s all designed to complement the care provided by physicians and hospitals.”
The program has won over many patients too. A recent Sun Health-conducted survey showed that almost 99 percent of patients surveyed would recommend the program to others. Results also indicate that patients grow measurably more confident that they can manage their health conditions during and after the 30-day program.
“Sun Health’s Care Transitions program is an example of an innovative and coordinated initiative to reduce avoidable readmissions. They are positively impacting their patients while improving quality and lowering health care costs,” said Fred Goldstein, president and founder of Accountable Health, a health care consulting firm. “Providers, accountable care organizations and other health plans could benefit from Sun Health’s expertise in this area.”
The readmission data presented here is calculated using raw, unadjusted Medicare claims for the specified periods of time. They do not indicate impact or take trends or other initiatives into consideration. These metrics are provided by CMS for performance monitoring purposes only and while they inform evaluative results, they do not constitute the entirety of the program evaluation.
About Sun Health
A long-standing champion for healthy living, nonprofit Sun Health is a community-based organization providing “pathways to population health” through philanthropy, senior living, community wellness programs and superior health care. Learn more at www.SunHealth.org.
