Community-Based Care Transitions Program

Case Study Submitted by: Jennifer Drago, Executive Vice President of Population Health, Sun Health
Country: United States of America (USA)

Sun Health, a long-standing non-profit organisation in Arizona, USA, has developed a customised care delivery model to better serve elderly patients within their community. The health service provider considers the social determinants of health, such as medication affordability, transportation, health literacy and social isolations and links the appropriate resources to patients.[1]

One of the main resources is the provision of  nurse ‘transition coaches.’ This means that when a patient is discharged from hospital, they are visited by a registered nurse (RN), who assesses the situation, provides education to the client, assesses medication and conducts a patient assessment, including an evaluation of the patient’s risk for depression or falls.[2]

The RN also provides advice to the client on how to answer questions related to their health and improve their understanding and management of their condition. If the RN encounters that the nature of the client’s condition has changed, they are able to undertake telemedicine consultations with the appropriate health care professional.[2]

In the United States of America, the Centre for Medicare and Medicaid Services found that approximately one in five patients (17.8%) discharged from hospital are readmitted within the first 30 days following initial admission.[1] These readmissions are often preventable and are often due to a lack of understanding or awareness about their condition and its symptoms, confusion over medications and how to take them; uncertainty about which health care provider to see when symptoms occur, and/or not following up with the primary care clinician within an appropriate timeframe.

As a result of this initiative, 99% of patients in the programme stated that they would recommend the service to others. The readmission rate has more than halved falling from 17.8% to 7.8%. [2]

  1. Advisory Board. This nurse-led approach cut hospital readmission rates by 56 percent. 2017 [cited 2017 16 November]; Available from:
  2. Sun Health. Sun Health Care Transitions. 2017  [cited 2017 16 November]; Available from:

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