 Publication Date: 6/17/2026
Abstract
Health care systems around the world are navigating a common set of challenges: increasing demand, workforce shortages, constrained resources, rising costs, and persistent disparities in health outcomes. As these pressures intensify, case management and transitions-of-care professionals are uniquely positioned to lead innovative, person-centered approaches that improve outcomes while strengthening the sustainability of health systems. This issue explores how collaboration, prevention, care coordination, and population health strategies are shaping the future of care delivery across diverse settings and populations.
The issue opens with an examination of England's Fit for the Future: 10-Year Health Plan (2025–2035) and an accompanying interview that reflects on the evolution of health care and case management through the lens of one patient's extraordinary journey from critical illness to recovery. Together, these articles highlight global efforts to shift care from hospitals to communities, embrace digital transformation, prioritize prevention, and empower patients and frontline professionals in designing the future of health care.
Building on these themes, a featured practice article examines the implementation of a multidisciplinary High Utilization Team (HUT) designed to address the complex needs of patients with frequent emergency department visits and hospital admissions. Through proactive identification, real-time intervention, and nurse- and social worker-led care management, the program demonstrates meaningful reductions in utilization and costs while improving care coordination for high-risk populations. The findings underscore the value of scalable, team-based care management models within value-based care environments.
The issue concludes with an important population health study examining the relationship between food insecurity and chronic disease among more than 72,000 adults receiving care in rural communities. The findings reinforce the critical role of social determinants of health in shaping outcomes and highlight the need for healthcare organizations to move beyond screening toward meaningful interventions that address underlying social needs.
Collectively, these articles illustrate the expanding role of case management in advancing prevention, addressing social determinants of health, coordinating complex care, and supporting system transformation. They provide valuable insights for healthcare leaders and practitioners seeking innovative approaches to improve outcomes, enhance patient experiences, and build more resilient and equitable health systems.
Learning Objectives
Featured Interview: One Patient’s Survival Through Adversity and the Health Care Team Who Made It Possible
1. Describe the role of interdisciplinary teamwork, communication, and care coordination in supporting positive outcomes for patients experiencing critical illness and complex recovery journeys.
2. Examine the impact of case management and transitional care planning on patient and family experiences during hospitalization, discharge, and long-term recovery.
3. Identify patient-centered communication strategies that help reduce uncertainty, build trust, and foster resilience among patients and caregivers during periods of medical crisis.
Transforming High Utilization Outpatient Care Management: A Multidisciplinary Model for Reducing Emergency Department and Acute Inpatient Utilization
1. Examine the design and implementation of a multidisciplinary high-utilization care management team.
2. Assess methods for integrating real-time data, analytics, and EMR workflows into outpatient care management.
3. Discuss how targeted RN/MSW-led strategies can reduce emergency department visits, inpatient admissions, and overall healthcare costs.
4. Evaluate how proactive patient identification and transitional care interventions improve healthcare utilization patterns.
From Screening to Action: Food Insecurity as a Driver of Chronic Disease in Rural Care Management
1. Analyze the relationship between food insecurity and chronic disease outcomes, including diabetes, hypertension, and obesity, within rural primary care populations.
2. Evaluate the limitations of routine food insecurity screening and identify gaps between screening and effective intervention in care management practice.
3. Apply care management strategies, such as standardized referral pathways, closed-loop follow-up, and community partnerships, to address food insecurity and improve chronic disease outcomes in rural settings.
Speakers:
Anthony Bennett
Anthony Bennett is a motivational and inspirational speaker. He has delivered keynotes, workshops, and live events across the UK and parts of the world for nearly two decades, inspiring audiences in boardrooms, schools, and conferences to rediscover hope, teamwork, and purpose. He worked as a Project Coordinator for Harvard Medical School conferences in London from 2017 to 2022 and has collaborated with charities, including Great Ormond Street Hospital Children’s Charity, helping secure a £7.5m partnership to expand pediatric care. His personal journey from patient to speaker underpins his messages on resilience, teamwork, and overcoming setbacks. He has been a patient speaker since the age of 18 and continues to engage audiences worldwide. Recognized for his positivity, Bennett was named one of the happiest people in the UK in the Independent on Sunday’s 2015 “Happy List”, a program celebrated by the Prime Minister for contributions to community wellbeing.
Diamond Staton-Williams, MHA, BSN, RN, ACM/CMAC, NE-BC
Diamond Staton-Williams received her ADN from Presbyterian Hospital School of Nursing in Charlotte, NC in 2003 where she served as the President of the Student Nurses Association. She went on to receive her BSN in 2006 from UNC Greensboro. In 2010, Diamond completed her Master’s in Healthcare Administration with a concentration in Organizational Leadership from Pfeiffer University. She is Certified as an American Case Manager, Certified Case Manager Administrator, and a Board-Certified Nurse Executive. Diamond is a volunteer with the Piedmont Black Nurses Association and North Carolina Nurses Association. Diamond is also a Board Member of Daymark Services in Cabarrus County, Communities in Schools Charlotte – Mecklenburg and Ascend Non-Profit Board. She is a member of the NCNA/ANA and NBNA. In November 2017, Diamond was elected to serve as a councilwoman for the Town of Harrisburg, NC. She is the first African American woman to serve on the council. Making history again, Diamond was re-elected to serve as a councilwoman for the Town of Harrisburg in November 2021. In 2022, Diamond made history again by becoming the first African American woman to be elected to the NC House of Representatives from Cabarrus County.
Nancy Scercy, BSN, MHA, NE-BC, CCM
Nancy Scercy, BSN, MHA, NE-BC, CCM is a nursing leader with experience in care coordination, access to care, and patient-centered operations. She currently serves as Manager of Nursing Care Connect at Atrium Health in Charlotte, North Carolina, where she leads teams responsible for supporting timely access, care navigation, and high-quality outcomes across the continuum of care. Nancy brings five years of direct case management experience, providing her with a strong clinical and operational foundation in utilization management, care coordination, and patient advocacy. Her background enables her to effectively bridge clinical practice with system-level strategy, ensuring care delivery that is efficient, compassionate, and outcomes-driven. She holds a Bachelor of Science in Nursing and a Master of Health Administration and is board certified as a Nurse Executive (NE-BC) and a Certified Case Manager (CCM). Nancy is recognized for her collaborative leadership style, commitment to staff development, and focus on advancing excellence in nursing practice and patient experience.
Karla Dowe, MSW, ACM-SW
Karla Dowe is a Master's level social worker with 24 years of experience at Atrium Health, spending the last 6 years working on the High Utilization Team. Karla is ACM-SW certified through ACMA.
Charlotte Dixon, BSN, RN, CCM
Charlotte M. Dixon, BSN, RN, CCM, is a Senior Care Manager with more than 20 years of experience at Atrium Health, practicing across acute care, ambulatory settings, and complex case management. Her professional expertise includes utilization management, high-utilizer population strategies, transitions of care, and interdisciplinary care coordination aimed at improving quality, efficiency, and patient outcomes across the continuum of care. Charlotte’s work emphasizes population health approaches that reduce avoidable utilization and support value-based care initiatives. A nationally certified Case Manager, Charlotte currently serves as President of the CMSA Charlotte Metro Chapter, where she supports education, professional development, engagement, and practice excellence for case management professionals. Her career reflects a sustained commitment to patient advocacy, workforce development, and continuous improvement in healthcare delivery. She is also a member of the American Case Management Association (ACMA) and values involvement in professional organizations to support ongoing growth and collaboration.
Stephanie Hernandez, BSN, RN, CMGT-BC, CCM
Stephanie Hernandez, BSN, RN, CMGT-BC, CCM is a certified nurse case manager with 10 years of experience across acute and ambulatory care settings. A graduate of the University of North Carolina at Charlotte School of Nursing, her background includes practice in a Level I trauma center medical surgical unit, inpatient care management with a focus on discharge planning, and outpatient care management serving high utilizer populations with frequent emergency department visits and hospital readmissions. Stephanie’s professional interests include mentoring, navigating complex systems, interdisciplinary care coordination, and initiatives aimed at improving outcomes while reducing avoidable utilization across the continuum of care. She is a member of the American Case Management Association (ACMA) and the Case Management Society of America (CMSA). In 2025 within her organization, she co created a departmental mentoring program that supported professional development and demonstrated positive outcomes for participants. Her work reflects a strong commitment to patient advocacy, autonomy, workforce engagement, and facilitating safe care transitions.
Kelli McKee, MSN, RN, BA-Ed, ACM-RN, CCM
Kelli McKee is a former high school educator turned nurse, bringing strong communication and advocacy skills into patient-centered care. She earned her Master’s in Nursing from Queens University of Charlotte and holds both CCM and ACM certifications. Currently with Advocate Health, she specializes in care coordination and case management, focusing on improving patient outcomes through education, collaboration, and evidence-based practice.
Sherdilia Lennon
Sherdilia Lennon is a Licensed Clinical Social Worker-Associate with 12 years of experience as a social worker. She is a certified social worker with nine years of experience with the Department of Social Services in both Adult Protective Services, and as a Guardianship social worker. She has one year of experience as a clinical case manager with Advocate Health and two years of experience as a social worker on the High Utilization Team with Advocate Health.
Lu Zhou, MS, MA
Lu Zhou is a senior healthcare analytics professional with more than a decade of experience applying data analytics and statistical methods to support care management, utilization management, and population health initiatives. Formally trained as a statistician and data scientist, Lu holds a Master’s degree in Economics and a Master’s degree in Operations Research and has worked in the healthcare industry since 2011 in senior analytics roles. Lu brings deep expertise in healthcare data analytics, statistical modeling, and program evaluation, with academic research published in the Canadian Journal of Economics. Since 2017, Lu has supported care management analytics, partnering with nurse case managers, social workers, physicians, and operational leaders to evaluate and optimize outpatient care management programs aimed at reducing avoidable emergency department visits and inpatient admissions. Lu has led and developed analytics initiatives across acute care, post acute care, and care management settings, supporting population health strategies, risk stratification, utilization monitoring, and performance measurement. Areas of specialization include utilization forecasting, capacity planning, causal inference modeling, and translating complex analytical results into actionable insights through dashboards that support clinical decision making, care management workflows, and executive oversight.
Lindsay R. Morse, DrPH, MSN, ACMA-RN
Lindsay Morse, MSN/NED, RN, ACM, is Vice President of Care Management for the University of Vermont Health Network, where she leads system wide strategies to strengthen care coordination and transitions of care across a rural, integrated health system. She has more than 25 years of experience across payer and provider settings and is recognized for advancing High Value Care in complex healthcare environments. Lindsay holds a Master’s in Nursing Education and is currently pursuing her Doctorate in Public Health (DrPH).
Keywords: Case management, transitions of care, health system transformation, value-based care, population health, care coordination, social determinants of health, food insecurity Collaborative Case Management Issue 101
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