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Collaborative Case Management Issue 98

Publication Date: 10/29/2025


Abstract
Effective care transitions for medically complex and socially vulnerable populations require innovative, collaborative approaches across health systems and community settings. This integrated analysis highlights three initiatives designed to improve outcomes among populations with high transitional care needs: medically fragile and technology-dependent (MFTD) children, individuals experiencing homelessness, and adults at risk for hospital readmission. Each project underscores the importance of interdisciplinary collaboration, targeted education, and attention to social determinants of health. A continuing professional development (CPD) program for private duty nurses caring for MFTD children improved clinical confidence and competency in complex pediatric care. In Chico, California, a Recuperative Care program, developed through hospital–shelter partnerships and guided by trauma-informed, person-centered principles, reduced readmissions and advanced health equity for unhoused patients. Similarly, at four Intermountain Health hospitals in Colorado, integrating Licensed Clinical Social Workers into transitional care teams decreased 30-day readmission rates from 8.9% to 7.6% and enhanced coordination between clinical and social services. Collectively, these initiatives demonstrate that outcomes improve when healthcare systems combine clinical expertise, community collaboration, and ongoing workforce development to meet both medical and social needs during transitions of care.


Learning Objectives

Supporting Private Duty Nursing Education for Medically Fragile and Technology Dependent Pediatric Patients
1. Analyze the impact of private duty nurse (PDN) shortages on hospital discharge delays and healthcare costs for medically fragile and technology-dependent (MFTD) children.
2. Evaluate the barriers home healthcare agencies face in training and retaining qualified PDNs and the implications for continuity of care for MFTD children.
3. Assess the effectiveness of a continuing professional development (CPD) program in improving the comfort and confidence levels of PDNs caring for MFTD children in the home setting.


Building a Sustainable Recuperative Care Program: Enhancing Health Equity for People Experiencing Homelessness Through Hospital-Shelter Partnerships, Part 1
1. Analyze the foundational components required to develop and sustain effective hospital-shelter partnerships in support of individuals experiencing homelessness, with a focus on the role of Recuperative Care models in promoting person-centered, trauma-informed care.
2. Evaluate the operational, clinical, and systemic challenges—including communication gaps, trust-building, and discharge planning barriers—that impact the implementation and scalability of Recuperative Care programs within the broader context of health equity.
3. Interpret longitudinal data and outcome measures related to patient health, hospital readmission rates, and health care utilization to assess the effectiveness and sustainability of Recuperative Care programs as a strategy to reduce health disparities among unhoused populations.


Enhancing Transitional Care: A Multidisciplinary Approach to Reduce 30-Day Hospital Readmission
1. Describe a practical multidisciplinary model for integrating LCSWs into RN-led transitional care.
2. Apply standardized SDOH assessment and referral workflows to reduce barriers after discharge.
3. Evaluate outcome and process measures (readmissions, engagement, RN–LCSW handoffs) to inform scale-up.


Speakers:
Lindsey Hird-McCorry; Julie Novak, BSN, RN; Michelle S. High, MSN, RN, CPN

Lindsey Hird-McCorry, BSN, RN, is a Nurse Coordinator with the Pulmonary Habilitation Program at Ann and Robert H. Lurie Children’s Hospital of Chicago with 24 years of experience caring for pediatric patients requiring chronic invasive mechanical ventilation and their families. She received the Nurse Exemplar Award, Family Educator in 2013, and Prince Nurse Scholar Grant in 2018.

Julie M Novak, BSN, RN, is a Neonatology Clinical Case Manager at Ann and Robert H. Lurie Children’s Hospital of Chicago with almost 30 years of experience caring for and discharging medically complex patients and families. She received the Nurse Exemplar Award, Expert Clinical Nurse in 2006, and Prince Nurse Scholar Grant in 2018.

Michelle High, MSN, RN, CNL, is a pediatric nurse at Ann and Robert H. Lurie Children's Hospital of Chicago with experience caring for children with medical complexity in transitional, intensive care, and emergency care settings. She received a Bachelor of Arts in Public Policy Studies from The University of Chicago and a Master of Science in Nursing from Rush University.

Amanda Wilkinson, LCSW, ACM-SW

Amanda Wilkinson is the Manager of Case Management Social Work at Enloe Health, a 308-bed Level II trauma center in Chico, California. She is a licensed clinical social worker by training and earned her Master of Social Work at California State University, Chico. She is an accredited case manager, social worker through the National Board for Case Management, and has been in health care for over 20 years. She serves as the secretary on the board of the American Case Management Association Northern California Chapter and is an active member of the education and public policy committee. Wilkinson is a member of the Society for Social Work Leadership in Healthcare and has a passion for innovative health care that addresses social determinants of health and works to improve health disparities.

Nina Marinello, DNP, MSN, BSN, RN

Nina Marinello is Manager of Care Coordination and Population Health at Intermountain Health. She leads transitional care and population health initiatives, focusing on quality improvement and reducing hospital readmissions

Keywords: transitions of care; interdisciplinary collaboration; social determinants of health; hospital readmissions; medically fragile children; recuperative care; care coordination; professional development; health equity; community partnerships

Collaborative Case Management Issue 98

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