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Membership Continuing Education
Connected Care Transitions: A Health System's Playbook for Better Outcomes

Publication Date: 9/24/2026

Note: This Course does not provide CEs.


Length: 60:2 minutes

Abstract
As value-based care reshapes how hospitals are accountable for outcomes, it has become imperative to solve the data, and workflow challenges these teams have lived with for years: limited visibility across the care continuum, fragmented workflows, and disconnected systems that slow decisions and obscure performance. The leaders pulling ahead are rethinking the workflow itself, not just working harder inside it. In this session, PointClickCare and a leading health system explore what that looks like in practice. Hear how this organization partnered with PointClickCare to support patients across transitions of care, from initial admission to post-acute through discharge planning. The conversation will spotlight what's moving the needle on length of stay, readmissions, and network performance, and what it takes to build a case management operation that drives those outcomes at scale.

The conversation will move between strategy, workflow, and the connected, AI-enabled solutions reshaping what case management teams can deliver today, with takeaways other organizations can apply to begin transforming their own care transitions.

Learning Objectives
1. Assess CMS Regulations related to transitions to post-acute care including Patient Choice and documentation requirements.
2. Identify the operational levers that have the greatest impact on length of stay, readmissions, and network outcomes.
3. Examine how connected technology and shared data across the care continuum can equip case management teams with real-time information at the point of decision, reducing rework and accelerating safe transitions.
4. Examine the measurable outcomes one health system has achieved — including improvements in length of stay, readmissions, and post-acute network performance — and the operational changes that drove them.
5. Apply lessons learned to assess your own organization's care transitions, identify priority opportunities for improvement, and make the case for connected case management to operational and executive stakeholders.

Speakers:
Andrew Borgia | Director of Strategic Accounts | PointClickCare

Andrew Borgia earned a Bachelor of Science in Marketing from Miami University and currently serves as Director of Strategic Accounts for PointClickCare. With more than 15 years of experience in the healthcare industry, Andrew has worked extensively with hospitals, health systems, accountable care organizations, and post-acute providers to improve care coordination, strengthen collaboration across the continuum of care, and support success in value-based care.

Britt Thompson MSN, RN, ACM-RN | Executive Director, Care Management | AdventHealth’s East Florida Division

Britt Thompson earned a Bachelor of Science in Nursing from Calvin University and a Master of Science in Nursing from American Sentinel University. She currently serves as Executive Director of Care Management for AdventHealth's East Florida Division, where she oversees care management, discharge planning, and community care services across eight hospitals. A Certified Case Management Professional and Accredited Case Manager, Britt is a nationally recognized leader who has presented at state and national conferences on innovative, patient-centered care models.

Andres Vallejo, MD, CMD | Chief Medical Officer | Spectrum Medical Partners

Dr. Andres Vallejo (vah-YEH-hoh) earned his Doctor of Medicine degree from Universidad de la Sabana and completed his postdoctoral fellowship and residency in Internal Medicine at New York University. He currently serves as Chief Medical Officer for Post-Acute Care and Chief Quality Officer at Spectrum Medical Partners. A board-certified internal medicine physician, Dr. Vallejo specializes in post-acute, long-term, and assisted living care and is dedicated to improving patient outcomes through quality improvement, interdisciplinary collaboration, and compassionate, patient-centered care.

Keywords: Care Transitions, Case Management, Health Technology, Data Integration

Connected Care Transitions: A Health System's Playbook for Better Outcomes

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