Case Management: A Model that Touches the Care Continuum

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Overview / Abstract:

Readmission reduction programs have popped up all over the nation as hospitals seek to avoid readmission penalties. Sharp Healthcare in San Diego California, was given the opportunity to participate in the Community-based Care Transitions Program (CCTP), through a grant from CMS to work with other hospital systems and the community-based organization Aging and Independence Services.

Connecting and communicating all the pieces is where the art of managing patients lies. Electronic data support is essential to success in not only transitioning hospitalized patients between services and departments, but enables hospital-based staff to connect and keep track of patients after they are back in the community.

This course describes the art of transitioning patients from the hospital back to the community: a case management model to help manage 30-day readmissions.

At the conclusion of the activity, attendees will be able to:
• Demonstrate the value of readmission risk assessments and bridging inpatient with outpatient case management
• Identify key components of the care continuum in the patient journey from hospital back into the community
• Define the critical community partnerships in the discharge plan for patients at risk for readmissions


Mar 15, 2020


Nurse Practitioner , Nursing CNE, Physician CME, Physician Assistant CME




$29 to $42

Credits / Hours



ACCME, Florida Board of Nursing

Presenters / Authors / Faculty

Cecile Davis, MSN, PHN, RN-BC
Cecile Davis is the Patient Safety Program Coordinator at Sharp Grossmont Hospital and has worked for Sharp HealthCare for 6 years. She has been a registered nurse for 34 years. Formerly, she was working at Sharp HealthCare, as the manager of the Community-based Care Transitions Intervention program (CCTP). This community-based innovations award from Medicare was an effort to reduce readmissions of Medicare patients as they transition from hospital to home. She also manages a Care Transitions Program (CTI) for the underserved at Sharp Grossmont Hospital.

Sponsors / Supporters / Grant Providers


Keywords / Search Terms

American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)

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