Care Transitions in Case Management

Bonnie Geld, MSW

Case management has grown beyond the walls of inpatient care sites; it now also supports and manages care in ambulatory settings and during fragile transition periods. Hospitals and health systems recognize that case management is the glue that maintains the patient’s progress. A skilled case manager not only helps the patient achieve personal health outcomes, but also helps improve the fiscal health of the healthcare organization.

Care Transitions in Case Management provides guidance on establishing case management processes to bridge the gap between care settings such as ambulatory, acute, and postacute with the goal of arming the patient with community resources to thrive at home. This book provides practical advice on patient and family engagement, strategies for partnering with payer case managers and utilization review, definitions of roles, and road maps for those involved in case management. Covering the entire lifetime of patient care, this book is a useful tool for case managers in all settings as they work to improve relationships and resources across the care continuum.

This comprehensive resource includes everything readers need to institute longitudinal care plans in their facility, including how to:

• Improve stakeholder communication and alignment
• Explain the entire continuum of care
• Implement longitudinal care models that address care throughout the lifespan of the patient across inpatient, emergency department, home health, patient home, and other settings

About the Author

Bonnie Geld, MSW, is the president of The Center for Case Management in Natick, Massachusetts. She has more than 20 years of experience in the area of case management and patient flow with a focus on process improvement, team building, and clinical integration. Geld has developed and implemented successful care management and patient placement programs across the country, both as an executive and on behalf of clients. She has launched a variety of educational programs, publications, and workshops on promoting team interventions, rapid cycle assessments, and integrated care planning. Geld previously served as the director of case management, social work, and patient placement at large academic medical centers, where she lifted the inpatient, ambulatory case management, and flow programs to a more contemporary platform.

Published: May 2018

Dimensions: 7x9
Expected Page Count: ~100
ISBN: 978-1-68308-712-0

Table of Contents

1. The rationale for change 

a. Changing payer models 
b. Connection to the Quadruple Aim 
c. New roles connected to new mindsets

2. Importance of new models to providers, payers, and consumers

a. Providers
b. Payers
c. Patients, families, consumers

3. Mechanisms for a successful continuum program

a. Patient and family engagement
b. Team-based care
c. Case management updates in care and policies
d. Technology

4. Building a new model

a. Nine steps toward a sustainable model
k. Vision
l. Staff engagement
m. Mission-critical principles
n. Shared goals
o. Leadership knowledge and skills
p. Break silos
q. Manage transitions
r. Education and literacy
s. Technology

5. New and unique opportunities for case management

a. Call centers/telehealth 
b. Remote monitoring 
c. Social media 
d. Other

6. Return on investment (ROI)

a. Identifying opportunities for grants and external funding sources 
b. Building the internal ROI 
c. Pay-to-play programs

7. Outreach opportunities

a. Homeless populations 
b. Rural living 
c. Frail elderly and silent minority

8. Behavioral and mental health

a. Recognizing the importance of emotional health and well-being 
b. Strategies to address depression associated with chronic care issues

9. Building the infrastructure

a. Organizational alignment 
b. Workflows 
c. Patient identification and risk

10. Creating a management action plan

a. Strategies 
b. Action steps and timelines

11. Political capital

a. What is it? 
b. How to use it

12. The future: Ensuring scalability

a. Predicting the future for case management practice