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Collaborative Case Management Issue 96

Publication Date: 5/7/2025


Abstract
The U.S. health care system, despite being one of the most technologically advanced and economically significant—constituting approximately 17% of the national GDP—continues to face critical challenges in access, affordability, and care coordination. Millions of Americans remain underserved, with nearly half of all families struggling to afford care and many forced to choose between basic needs and medical services. Addressing these systemic inefficiencies, one health care organization implemented a targeted approach to improve patient transitions from hospital to post-acute care. By establishing a Post-Acute Referral Center and leveraging electronic medical records and cross-sector collaboration, the initiative achieved measurable outcomes including an 18% reduction in excess hospital days and improved patient flow. In parallel, broader innovations in value-based care—driven by digital technologies and participatory design—are reshaping integrated health and social care models. The VALUECARE model exemplifies this shift, using ICT tools to support older adults with comorbidities in a more personalized and outcomes-driven framework. Together, these developments point toward a more efficient, patient-centered, and digitally supported health system that addresses both immediate operational needs and long-term structural reform.


Learning Objectives

Managing length of stay reduction through effective discharge planning
1. Analyze the factors contributing to length of stay (LOS) challenges in health care settings.
2. Implement discharge planning rounds to improve patient flow and reduce length of stay.
3. Evaluate the impact of discharge planning rounds on clinical outcomes and hospital efficiency.


Implementing a Post-Acute Referral Center (PARC) to Streamline the Discharge Process
1. Review the rationale for a focused approach to coordination of post-acute services with inclusion of a Shared Governance structure.
2. Describe aspects of a successful process improvement initiative to improve outcomes.
3. Establish a common foundation related to transition management that can be used across the health care system.


VALUECARE Model for Value-Based, Integrated Health and Social Care Services Delivery Supported by ICT for Older Adults
1. Describe the core principles and components of the VALUECARE model as an example of value-based, integrated health and social care for older adults with comorbidities.
2. Explain how participatory co-design and qualitative data collection methods (e.g., focus groups and interviews) were used to shape a patient-centered care model across multiple European countries.
3. Identify the role of digital technologies and the eHealth Enhanced Chronic Care Model in supporting the implementation of value-based care within integrated care delivery systems.


Speakers:
Diane DiFiore, DNP, MHSA, RN, NEA-BC, ACM-RN

Dr. Diane DiFiore, DNP, MHSA, RN, NEA-BC, ACM-RN, is an accomplished health care executive with expertise in quality management, process improvement, and care management. Her leadership at organizations like Beaumont Health and Corewell Health East has led to national recognition for excellence in care management, patient experience, and operational efficiency. In addition to her leadership roles, Dr. DiFiore is dedicated to advancing health care through education, presenting at national conferences, and publishing articles on care management best practices. Her work spans many areas, from nurse recruitment to strategic planning, and she holds advanced certifications in case management and nursing leadership. Dr. DiFiore holds a Doctor of Nursing Practice (DNP) and is committed to fostering sustainable, high-quality health care solutions.

Anita Dunham, MS, BSN, CMAC, CDP, NE-BC; Emily Mills, RN BSN; Christy Gerdes, BSBA; Hailey Twietmeyer, MSW

Nita Dunham has 30 years’ experience in health care and has been a Case Management leader for the past 14 years.? Nita graduated as a Registered Nurse with her Masters in Administration from the University of South Dakota and holds certifications as a Long-Term Care Administrator, Certified Case Management Administrator, Lean Green Belt Certified, a Certified Dementia Practitioner and is a Certified Nurse Executive. She has a passion for process improvement and team development and has co-authored three case management-focused articles published in JAMDA and the “Collaborative Case Management” journal.

Emily Mills has worked with the Monument Health Rapid City hospital for?13 years.? She holds a bachelor’s degree in nursing from South Dakota State University.? Previously she worked as a Lead Case Manager and was an Ortho/Neuro nurse prior to coming to Case Management.? Emily has served on the Case Management Practice Council and was selected for the Monument Health’s Emerging Leaders Program.

Christy Gerdes has nearly 20 years’ experience in the Healthcare both in the hospital and ambulatory settings.? She graduated with a bachelor’s degree in Business Management from the University of Nebraska-Lincoln.? She has worked as a Performance Engineer with Monument Health for the past four years and is Lean Green Belt Certified.? She thrives on bringing teams together to understand process improvements and guide teams to champion change.? She currently serves as an Office 365 and a LiveWell Champion for Monument Health.

Hailey Twietmeyer has worked with Monument Health Rapid City Hospital for 4 years in the Care Management Department. She holds a master’s in social work from the University of Missouri-Kansas City, a minor in psychology, and holds a multicultural certification. Previously worked as a social worker in the outpatient setting specializing in severe and persistent mental health.

Mireia Ferri Sanz; Alejandro Gil-Salmerón; Maite Ferrando; Oscar Zanutto; E. L. S. Bally; Sara Ceron; Demi Cheng



Keywords: value-based care, integrated care, eHealth, ICT in health care, post-acute care, care coordination, hospital discharge planning, health policy, patient-centered care

Collaborative Case Management Issue 96

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