Module C: Patient Engagement & Care Transitions

CE Credits: 1.25

This module explores a vital duty of the case manager: effectively communicating with patients, so that they can be actively engaged with their ongoing care. It begins by recognizing the power of the transdisciplinary team, as members work together to coordinate care through transitions—like from a hospital to a skilled nursing facility, or to home while following up with a specialist. Next, it looks at how a CM’s skills in cultural competence and recognizing health literacy can affect a patient’s engagement with his or her own care. Last, the module explores how case managers can use various methods—from telehealth to motivational interviewing and telehealth coaching—to boost the odds of a patient’s engagement and, as a result, encourage a better outcome.

Learning objectives: After completing this module case managers will be able to:
» Review transdisciplinary team interactions to foster seamless care transitions
» Describes the role of cultural competence and health literacy in obtaining patient engagement
» Review the importance and utilization of teach-back methods
» Discuss the integration of telehealth into population health and care transitions
» Describe strategies to incorporate motivational interviewing into telehealth interventions
» Recognize the importance of caregivers in telehealth coaching and care transitions


Advance your professional practice: Since case managers are on the front line with patients, helping them navigate the various levels of care, it is crucial that we are able to communicate with them in efficient and effective ways, so that we can empower them with the information they need to continue their self-care and achieve the best possible outcome for their situation.

Improving organizational performance: Ongoing care for patients, especially those with chronic conditions, is a team effort, given the impacts that specialists, nurses, behavioral health specialists, pharmacists and more can play in a patient’s recovery. When we are consistent in engaging patients in their own care, we can offer the patient the best odds for a positive outcome, while lowering the chances of unnecessary hospitalizations or added costs.