Reducing Readmissions Part 4: The Case Manager’s Role

Video Runtime: 60 Minutes; Learning Assessment Time: 38 Minutes

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