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presented by Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN and Nancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM
Financial: Colleen Morley receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.
Nonfinancial: Colleen Morley has no competing nonfinancial interests or relationships with regard to the content presented in this course.
Financial: Nancy Skinner receives compensation from MedBridge for this course. She is a consultant/educator at Encompass. There is no financial interest beyond the production of this course.
Nonfinancial: Nancy Skinner has no competing nonfinancial interests or relationships with regard to the content presented in this course.
Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.
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Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN
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, care coordination through better communication, and population health…
Read full bioNancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM
Nancy has, for the past 30 years, served as a case manager, director of case management, and international case management educator. In her current role as principal consultant for Riverside HealthCare Consulting, she advances programs that promote excellence in care coordination and other transitional care strategies. She has presented more than 400 on-site programs and…
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1. Transitions of Care
In this chapter, we will define the concept of transitions of care and discuss the impact that transitional care has on the healthcare delivery system. The impact of good and poor transitions on healthcare outcomes, costs, and patient experience is explored.
2. Transitions of Care: Quality Metrics
Continuing the discussion on transitions of care, we study the metrics that are closely associated with transitions of care (readmissions, patient outcomes, patient satisfaction, financial outcomes). An in-depth discussion of the Medicare Hospital Readmissions Reduction Program features prominently. This chapter begins a discussion on defining transitional care gaps and the risks/effects of each on the transition plan.
3. Transitional Standards
We will continue the discussion of transitions in healthcare delivery with a review of the Transitions of Care Standards from the American Case Management Association. Following established standards of care can decrease the impact of the care gaps and create a better overall transitional experience. The standards are explored in detail in this section, and examples are used as illustration.
4. Advancing Appropriate Transitions of Care
In previous sections, the concept of readmissions has been discussed. This chapter will introduce the readmission prevention concept. We will discuss the available tools and resources that clinicians can use with their patients to enable each patient to more effectively self-manage through the transition process. Examples from leading transitions-of-care organizations are highlighted.
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