A great deal of attention has been directed by hospitals and health systems to the evolution of the accountable care organization (ACO) initiative. With the selection of the Pioneer group of health systems by the Centers for Medicare & Medicaid Services to participate in the initial program, the opportunity for most hospitals and health systems to participate in this Medicare shared savings program will be some time in coming.

In the meantime, the reduction in Medicare provider payments through the value-based purchasing and unwarranted readmission focus is soon to be a reality that will have significant impact in the near term. As a result, healthcare providers should be addressing these issues with the same level of interest that has been devoted to ACOs.

There are real opportunities through partnerships and collaboration to meet these challenges. One example is the Care Transitions Program developed and implemented by Sun Health, a Phoenix-based organization operating three retirement living centers which include assisted living and skilled nursing facilities. 

Given the findings by CMS that one in five patients discharged from acute hospitals will be readmitted within 30 days following the initial admission, Sun Health has partnered with the Banner Boswell and Del E. Webb Medical Centers to create a care transition program to assist its residents during the critical period following hospital discharge.

Patients enrolled in the care transition program receive an initial hospital visit to introduce the program, and within 24 to 48 hours of discharge receive a home visit by a care manager to review medication schedules, provide education about the patient's condition, ensure timely follow-up physician care and help connect the patient to other community resources. Phone calls are made during the 30-day program to reinforce the patient education measures and to answer questions.

The initial reports are very promising. Of the first group of patients introduced to the program, there were no returns to the hospital during the initial critical 30-day period. The Sun Health Care Transitions Program is an excellent example of how hospital providers and post-discharge care facilities can work together to meet the challenge of improving care for patients and mitigate the impact of Medicare payment reductions resulting from the CMS focus on too-frequent patient readmissions.

Mike Stephens blogs regularly at Action for Better Healthcare.