Barbara Mason Brad Reed USE

Barbara Mason
Vice President of Home and Community Based Services

Care Transitions

The Centers for Medicare and Medicaid Services reports that one in five patients discharged from an acute-care hospital is readmitted within the first 30 days of the initial admission. Often, these readmissions are preventable, sometimes result from confusion over medications, difficulty understanding or following discharge instructions, or lack of follow-up care. Sun Health Care Transitions is combating high rates of hospital readmissions among high-risk Medicare beneficiaries with a complimentary, evidence-based program that empowers patients and fosters healthy independence. Our team of expertly trained nurses and care managers provides 30 days of one-on-one assistance to patients who are living with chronic diseases, such as congestive heart failure, acute myocardial infarction, chronic obstructive pulmonary disease and diabetes. During that time, Care Transitions representatives educate patients on their conditions and the lifestyle changes necessary to manage them, connect patients with community health and social resources that foster success, and provide the comfort and security patients sometimes need to tackle their ailments. Care Transitions participants benefit from:

  • One-on-one, in-home nursing assessments (within 48–72 hours of hospital discharge)
  • Chronic-disease education
  • Medication review and education
  • Home-safety evaluations
  • Information on community support resources
  • Weekly follow-up calls from licensed practical nurses
  • Social worker support, as needed