Follow ACMA
Twitter Facebook Linkedin Instagram
Logo
v
GO
Membership Continuing Education
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

Back to CE List Go to Member CE
Announcements

SAVE THE DATE | ACMA 2026 National Conference

Join us for ACMA 2026 National Conference, April 20-23, 2026 in Orlando, FL. Don't miss out on the premier case management and transitions of care conference of the year!
Experience ACMA at National!

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

Care Transitions Today Podcast

Our upcoming series, Case by Case, is co-presented by the American Case Management Association (ACMA) and the Association of Physician Leadership in Care Management (APLCM). In the Case by Case series, we delve deep into real-world medical cases, sharing experiences, best practices, and innovative approaches to patient care. Led by returning experts Dr. Rebecca Severe and Dr. Sweta Singh, along with rotating guest panelists, our hosts bring you a new case study, offering a unique learning opportunity for health care professionals at all levels of experience. Learn more!

Get ACMA News in the Palm of Your Hand

Join the conversation with ACMA! Text the keyword ACMA to 844-554-2497 to stay up to date on all the latest news and announcements, delivered straight to your phone!

Karen Vanaskie Scholarship Fund

Karen Vanaskie was one of case management's brightest and most dedicated professionals. She was serving as Secretary / Treasurer on the ACMA National Board of Directors at the time of her unexpected passing on June 21, 2024.

At the request of Karen's family, ACMA has set up the Karen Vanaskie Scholarship Fund. Karen was passionate about the need for case management certification. She actively supported her staff in pursuing the Accredited Case Manager (ACM) Certification. To continue her legacy, this scholarship fund will cover the cost of their ACM certification application fee for those to whom it is awarded. We believe this continues Karen's legacy.

To apply for the scholarship, click here. For eligibility details, please see below.

To donate to the scholarship fund in Karen's memory, click here.

2024 National Survey Results are Live!

ACMA and APLCM are proud to announce the latest iterations of the National Case Management and Transitions of Care Survey and the Physician Leaders in Care Management Survey, which have been the only source of comprehensive data for the case management industry since 2001. This ongoing research incorporates over 20 years of data, offering invaluable insights into the evolving landscape of case management, transitions of care, and physician advising. Access the full reports through your ACMA and APLCM member portals!

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
© American Case Management Association.