Module D: Enhanced Care Transitions

CE Credits: 1.75


This module explores one of the most basic but critical parts of a CM’s job: navigating a patient through the transitions of care within his or her treatment. It begins by detailing what the continuum of care can look like, from inpatient care to perhaps a skilled nursing facility or home, with ongoing care from primary care physicians, nutritionists, or mental health specialists. Next, the module details the kinds of skills required to finesse these transitions—such as accountability and good communication skills—and how those skills will be needed for special patients, such as children. Last, the module details how CMs can troubleshoot with patients at higher risk of hospital readmission, and how to help patients empower themselves for better self-care going forward.

Learning objectives: After completing this module the case manager will be able to:
» Review the continuum of the case management activities
» Describe the core competencies in care coordination
» Discuss care coordination concerns with pediatric patients
» Identify essentials in patient transitions of care
» Discuss care planning for patients who are at risk for readmission
» Recognize the importance of improving patient engagement and enhancing patient satisfaction

Advance your professional practice: Helping a patient make a transition of care successfully is a vital part of our role as CMs. When we master those skills—and understand the possible pitfalls of poorly managed transitions—we can help patients achieve better outcomes and prevent costly readmissions.


Improve organizational performance: One of a hospital’s greatest expenses can come from readmissions—some that will not be reimbursed by insurance providers—of patients with chronic diseases or preventable conditions. When our team works efficiently to create solid discharge plans for patients—getting them into the right levels of care at the right time—we can improve their outcomes and minimize our health organization’s un-reimbursed costs.