Sg2 Case Study: Care Connectivity Begins at Home

This community-based provider, part of Sutter Health, has been offering an array of home care services for decades, relying on a foundational integrated care model to deliver coordinated, patient-centric services.


As part of the Sutter Care at Home division, the Sutter Center for Integrated Care focuses on advancing best practices for patient engagement via its Integrated Care Management (ICM) model. The evidence-based ICM methodology incorporates an expanded role for home health clinicians aimed at strengthening connections between acute and home-based care.

  • A home health liaison RN collaborates with hospital case managers once patients have been identified as high risk for readmission, been deemed clinically appropriate for home care and have approved their enrollment in the Sutter Care at Home program.
  • During bedside visits, the liaison nurse educates patients about the discharge process and how to recognize and respond to signs of declining health; assesses comprehension; evaluates signs of depression; and identifies patients’ personal health goals.
  • To ensure a systematized approach, all visit information is entered into the EMR prior to discharge. Additionally, the SBAR (Situation, Background, Assessment, Recommendation) communication framework is hardwired into the EMR and used during all critical information transfers.
  • Within 24 hours of discharge, a home care RN case manager makes the first home visit. The RN performs a thorough cardiopulmonary assessment and medication reconciliation, assesses home safety, identifies key areas for increasing skills in self-management, and reviews the patient’s personal goals.
  • Ongoing management protocols include weekly presentation of high-risk patients at care conferences for the first month postdischarge.

Patient-centered program components include:

  • Patient-friendly medication lists, high-alert medication “stoplight” tools and personal health records
  • Remote monitoring, especially for patients with low self-confidence and health literacy
  • Evidence-based self-management educational materials

In the first 8 months following the program’s launch, results showed the following:

Related resources:

Contact us to find out more about how Sg2 can assist your organization with developing care at home programs and optimizing the post-acute care segment of your care continuum.

CAHPS = Consumer Assessment of Healthcare Providers and Systems. Source: Sg2 Interview With Sutter Care at Home, 2014.


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