Reducing Readmissions Part 4: The Case Manager’s Role
Presented by Colleen Morley
This course focuses on the essential and evolving function of the case manager as a longitudinal care leader who is critical to reducing hospital readmissions across the care continuum. It details the various formal roles of case managers (e.g., in hospitals, managed care organizations [MCOs], and accountable care organizations [ACOs]) and the core strategies they employ, such as commencing discharge planning within 24 hours of admission, using evidence-based tools like LACE and transitional care models, and collaborating closely with postacute providers. Ultimately, the presentation emphasizes that effective readmission prevention requires case managers to move beyond clinical tasks to address systemic challenges, patient engagement, and social determinants of health, viewing themselves as key advocates and change agents within the healthcare system.
Learning Objectives
- Outline the responsibilities of case managers in reducing hospital readmissions
- Identify key strategies used by case managers to enhance care transitions and discharge outcomes
- Evaluate opportunities for collaboration with postacute care providers to support readmission reduction
- Interpret the role of data and predictive modeling in informing case management decisions
- Analyze quality metrics commonly used by case managers to monitor and reduce readmissions
- Examine common challenges case managers encounter in achieving readmission reduction targets and approaches to address them
Meet your instructor
Colleen Morley
Dr. Colleen Morley has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for more than 12 years and piloting quality improvement initiatives focused on readmission reduction and…
Chapters & learning objectives
1. The Case Manager’s Role in Preventing Readmissions
Chapter 1 outlines the diverse and evolving formal roles of case managers—from longitudinal coordinators to specialized roles in MCOs and ACOs—all focused on seamless care transitions and addressing social determinants of health.
2. Strategic Approaches in Case Management
Chapter 2 details key readmission prevention strategies, including commencing discharge planning within 24 hours of admission and utilizing established transitional care models like RED, BOOST, and CTI to standardize interventions and improve patient engagement.
3. Collaboration With Postacute Providers
Chapter 3 highlights the critical need for case managers to facilitate structured handoffs, integrated care plans, and regular communication with postacute providers (SNFs, home health, etc.) to ensure continuity of care.
4. Leveraging Data and Measuring Outcomes
This chapter explains how case managers use predictive risk-stratification tools like LACE, HOSPITAL, and PATIENT scores, along with real-time dashboards, to identify high-risk patients and measure performance against quality metrics like the Hospital Readmissions Reduction Program (HRRP).
5. Addressing Challenges in Case Management Practice
The final chapter of this course examines common barriers to success, such as high caseloads, system fragmentation, and burnout, advocating for structural support, better resource integration, and an organizational culture that addresses health literacy and implicit bias.
6. Question and Answer Session
In this chapter, Colleen Morley will address common questions about reducing readmissions.
More courses in this series
Reducing Readmissions Part 1: Understanding the Landscape
Colleen Morley
Reducing Readmissions Part 2: Evidence-Based Strategies
Colleen Morley
Reducing Readmissions Part 3: Social Determinants of Health
Colleen Morley
Reducing Readmissions Part 4: The Case Manager’s Role
Colleen Morley
Reducing Readmissions Part 5: Best Practices and Future Directions
Colleen Morley
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