Case Management: A Model that Touches the Care Continuum

Readmission reduction programs have popped up all over the nation as hospitals seek to avoid readmission penalties. Sharp Healthcare in San Diego California, was given the opportunity to participate in the Community-based Care Transitions Program (CCTP), through a grant from CMS to work with other hospital systems and the community-based organization Aging and Independence Services.

Connecting and communicating all the pieces is where the art of managing patients lies. Electronic data support is essential to success in not only transitioning hospitalized patients between services and departments, but enables hospital-based staff to connect and keep track of patients after they are back in the community.

This course describes the art of transitioning patients from the hospital back to the community: a case management model to help manage 30-day readmissions.

At the conclusion of the activity, attendees will be able to:
• Demonstrate the value of readmission risk assessments and bridging inpatient with outpatient case management
• Identify key components of the care continuum in the patient journey from hospital back into the community
• Define the critical community partnerships in the discharge plan for patients at risk for readmissions