Follow ACMA
Twitter Facebook Linkedin Instagram
Logo
Membership Continuing Education
Achieve Optimal Outcomes with a Patient-Centric Care Coordination and Discharge Planning Model

Publication Date: 3/12/2024


Length: 60 minutes, 49 seconds

Content Level: 1 Advanced, General CE

Abstract
Uncoordinated, fragmented patient discharges can lead to poor patient outcomes and costly readmissions. This presentation shares how a large integrated delivery and finance system explored the allocation of resources and redesigned a more efficient system approach to clinical care coordination and discharge planning. Discussion of model components includes a new executive leadership structure, a single point of contact responsible for discharge planning, a cascading clinical ladder, and alignment for care managers, social workers, post-acute liaisons and transition coordinators.

Learning Objectives
1. Assess ways to evaluate hospital resources to better coordinate care and discharge planning.
2. Describe how existing roles can be reimagined and restructured to better meet the needs of the patient and their family.
3. Identify ways the role of the social worker can be elevated to improve outcomes in the in-patient, acute care setting.
4. Demonstrate the importance of creating a single point of contact for patients during the discharge process.

Speakers:
Jennifer Hall, MSN, RN, CCM, ACM-RN | Senior Director, Care Management | UPMC

Jennifer Hall is a registered nurse, certified and accredited case manager who has held progressive leadership roles within care management at UPMC for the past 17 years. She began her UPMC career as a nurse at UPMC Passavant and transitioned to care management in 2005 at Magee Women’s Hospital. She was promoted to Manager of Health Management at Magee in 2007, where she served for several years before taking a role as Director of the Care Management Department at UPMC Passavant in 2012. Most recently, she was promoted to Senior Director for Clinical Care Coordination and Discharge Planning for UPMC. In addition to her work at UPMC, Jennifer has served in various roles with the ACMA Western Pennsylvania Chapter, including Treasurer, President Elect, President and since 2020, Nominations Committee/Vendor Chair.

Dr. Amanda Lenhard, MD | Senior Medical Director, Clinical Care Coordination and Discharge Planning | UPMC

Dr. Amanda Lenhard completed her undergraduate education at Texas A&M University and earned her medical degree from Case Western Reserve University School of Medicine. Lenhard joined UPMC in December 2020 as Chief of the Department of Medicine at UPMC Shadyside, Department of Medicine lead for Quality and Chief of the Section of Hospital Medicine. Prior to joining UPMC, she served as Chief of Staff, Chief of Hospital Medicine, and Chief of Quality for the Department of Medicine at the University of Toledo Medical Center and has held positions in management, utilization review and physician advising. She is an active and proud member of the UPMC Health Services Division Throughput Excellence Committee and the UPMC Health Services Division Throughput Hospital Consultant Team. In May 2022, Dr. Lenhard accepted the role of Senior Medical Director, Clinical Care Coordination and Discharge Planning for the Health Services.

Keywords: discharge planning, social work, acute care

Achieve Optimal Outcomes with a Patient-Centric Care Coordination and Discharge Planning Model

Back to CE List Go to Member CE
Announcements

Register Today! | 2026 Leadership and Physician Advisor Conference

The ACMA/APLCM 2026 Leadership and Physician Advisor Conference is November 15-17 in Nashville, TN! Leaders in Case Management, Transitions of Care, Social Work, Health Plans, Health Care Administrators, Medical Directors, Chief Nursing Officers, and Physician Advisors, this conference has everything you need. Learn more and register.

Save the Date | ACMA 2027 National Conference

Join ACMA in Las Vegas, NV, April 18-21, 2027. Save the date.
Experience ACMA at National!

ACMA National Survey is Live!

Help shape the future of case management by completing the annual ACMA National Survey. The survey takes approximately 30 minutes, and all responses are confidential. Please participate and share with interested colleagues.
Learn more and participate!

ACMA Swag is Now Available

Support ACMA's mission and wear or show off your ACMA pride!
Get your swag today!

ACMA and APLCM are Partnering Organizations | International Case Management Conference

We are pleased to announce that ACMA and APLCM are partnering organizations for the inaugural International Case Management Conference, taking place September 17-18, 2026 at the Pullman London St Pancras. This collaboration brings together global leaders in case management and care delivery to support a shared vision for advancing health care systems worldwide. As partnering organizations, ACMA and APLCM will contribute their expertise and international perspectives to help shape critical discussions on the future of care management and health system innovation.
Learn more.

Share Your Research | Collaborative Case Management

Do you have a project or measurable initiative you've instituted at your organization? Have you conducted research on a current issue in the field? Share your experiences and results with your professional community! Email your proposal or questions: vmatthews@acmaweb.org.
Learn more!

Now Accepting Presentations for Chapter Conferences

We are now accepting presentations for upcoming ACMA chapter conferences. If you have a unique solution, intervention or strategy to improve case management, this is a great opportunity to share your knowledge and be a part of ACMA's national-caliber education at the local level. There is no deadline to submit; presentations will be accepted throughout the year so you can prepare a submission as your schedule allows.
Submit a presentation!

SAVE THESE DATES | National Case Management Week

2026 - October 11-17
2027 - October 10-16
2028 - October 8-14

Quick Links

Products & Resources

Events & News

American Case Management Association
17200 Chenal Parkway Ste 300 #345
Little Rock, AR 72223
Phone: 501-907-ACMA (2262)
Fax: 501-227-4247
Privacy Policy
Cookie Policy