Transitional Care Case Management

Purpose: The purpose of this course is to understand the role of the case manager in transitioning the patient from one level of care to another level of care along the continuum. The case manager who stands in the gap between different levels of care is the health care staff person who creates a transparent move so that the patient’s plan of care is carried out to prevent readmissions to higher levels of care. The case manager in this role is often given the title of ‘Transitional Case Manager”. There is usually a handoff from the former case manager to the transitional case manager. The transitional case manager may handoff care at some point to another case manager. This course will highlight the critical role of the transitional care case manager which is a relatively new role in the healthcare industry.

Course Objectives:

  • Define the role of the transitional care case manager.
  • Discuss how the role of the transitional care case manager differs from those of other case managers.
  • Discuss the desired experience and background of the transitional care case manager.
  • Discuss the standard of practice for a transitional case manager.
  • Define the difference between the levels of care along the healthcare arena.
  • Define the expectations for the transitional care case manager when he/she functions in different levels of case management simultaneously.
  • Explain how transitional care case managers keep the healthcare team updated on changes in conditions.
  • Define differences between internal transitional care case managers and external transitional care case managers.
  • Analyze the three case studies and identify the role of the transitional care case manager in each case.

Expected Outcome:
The role of the transitional care case manager is to fill in the gaps between case managers from various levels of care. The transitional care case manager receives handoffs and communications from one level of case manager. The plan of care along the continuum may involve handoffs to other case managers and this inception is expected to be communicated by the transitional care case manager. Upon completion of this course, the participant will be able to clearly define and identify the purpose and responsibilities of the transitional case manager in the healthcare setting.