 Publication Date: 12/23/2025
Abstract
Care coordination and case management are increasingly critical in health care systems challenged by rising patient complexity, social vulnerability, and the need for person-centered, integrated care. This abstract synthesizes evidence across acute care discharge planning, telehealth engagement, and long-term recovery to examine what care coordination approaches work, for whom, and under what circumstances. A structured Discharge Complexity Criteria and Scoring (DCCS) tool is presented as an effective method for identifying patients at high risk for delayed discharge by systematically integrating medical, social, and logistical factors, enabling earlier intervention, more efficient transitions of care, and improved hospital capacity and patient outcomes. Complementing system-level strategies, person-centered communication is explored through a case example demonstrating how addressing aging Veterans by military rank in telehealth settings can enhance trust, engagement, and adherence by reinforcing dignity and partnership. Extending across the continuum of care, findings from a 10-year mixed-methods realist evaluation of person-centered case management following severe injury confirm that tailored, intensity-appropriate interventions—particularly proactive coordination, advising, and emotional and motivational support—significantly contribute to recovery, participation in life roles, and sustained well-being. Together, these findings underscore that effective care coordination is multidimensional, context-sensitive, and relational, requiring structured tools, respectful communication, and person-centered case management models to optimize outcomes across diverse populations and care settings.
Learning Objectives
Discharge Complexity Criteria and Scoring
1. Define the concept of discharge complexity and explain its relevance in acute care settings, particularly for patients with complex medical and social needs.
2. Describe the structure and purpose of the Discharge Complexity Criteria and Scoring (DCCS) tool, including its components and scoring methodology.
3. Identify key medical, social, and logistical factors that contribute to delayed discharge and how they are systematically assessed using the DCCS.
4. Analyze how early identification of discharge barriers through DCCS can improve care coordination and transition planning.
5. Evaluate the impact of DCCS implementation on hospital capacity management, discharge efficiency, and patient outcomes.
Guiding Journeys with Respect: How Addressing Rank— ‘Colonel’—Revolutionized Veterans’ Telehealth Care During National Case Management Week
1. Demonstrate how to respectfully inquire about and address veterans by their military rank during telehealth interactions.
2. Apply rank-aware communication strategies to transform resistant veterans into active participants in home telehealth programs.
3. Integrate military service history into culturally humble care approaches that honor veteran identity and improve health outcomes.
A Realist Evaluation of Case Management Models for People with Complex Health Conditions Using Novel Methods and Tools—What Works, for Whom, and Under What Circumstances?
1. Describe the evolution of case management from a generalist model to a person-centred, integrated care approach and its alignment with international best-practice frameworks.
2. Explain how realist evaluation methods were used to identify relationships between case manager actions, contextual factors, and recovery outcomes following severe injury.
3. Identify key person-centred case management actions and intensity levels that contribute to improved recovery, goal attainment, and participation in life roles for individuals with traumatic brain injury and other severe injuries.
Speakers:
Edwin A. Espiritu, MSN, RN, ACM-RN, CCM
Edwin Espiritu, MSN, RN, ACM-RN, CCM is a health care leader with expertise in case management, care coordination, and clinical operations. He serves as a Director of Case Management, where he leads multidisciplinary teams to improve patient outcomes, optimize care transitions, and support efficient, patient-centered care delivery. With a Master of Science in Nursing and multiple professional certifications, Espiritu brings a strong blend of clinical knowledge and operational leadership to complex healthcare environments. He is actively engaged in advancing best practices in case management through professional service, education, and collaboration. Known for his strategic, data-informed approach and commitment to quality improvement, Espiritu is dedicated to strengthening systems of care and elevating the role of case management across the continuum.
Gabriel J. Sapalaran, Jr., MSN-PHC, RN, CTC, FSIEN
Gabriel J. Sapalaran, Jr., MSN-PHC, RN, CTC, PhD-NS (S), FSIEN is a registered nurse with extensive experience in remote patient monitoring, home telehealth, and case management. He currently serves as an RN Case Manager in Remote Patient Monitoring and Home Telehealth at the Birmingham VA Medical Center, where he leverages technology-enabled care to support patients with chronic and complex conditions. Dr. Sapalaran holds a Master of Science in Nursing with a public health concentration and brings decades of clinical experience across diverse care settings in the Philippines and the United States. His professional interests include telehealth, geriatrics, chronic disease management, and nursing informatics. A Fellow of the Society of Internationally Educated Nurses, he is committed to advancing equitable, patient-centered care through innovation, education, and professional leadership.
Sue Lukersmith, Luis Salvador-Carulla, Younjin Chung, Wei Du, Anoush Sarkissian, and Michael Millington
Keywords: Case management, person-centered care, discharge planning, discharge complexity, care transitions, social determinants of health, patient engagement, telehealth, Veteran-centered care, integrated care, recovery pathways, complex health conditions, care models Collaborative Case Management Issue 99
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