Community Health
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Bridging the Gap: The Vital Role of Community Health Workers in Transforming Care

BY DEBRA COOPER, SUNFLOWER HEALTH PLAN
A community health worker (CHW) is someone who works directly with the community to support their health and well-being. Because they are part of the community and deeply connected to it, people trust them. This trust helps CHWs bridge the gap between the community and health or social services, making it easier for people to access care and ensuring the services are delivered in a way that respects their culture and needs.

Care Corner
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The Benefits of a Daily Stretching Routine

BY JOYACE G. USSIN, MSN, RN, BSBM, CCM
The new year has begun, and with it myriad new resolutions, constitutions and subscriptions with promises to do better, live well and excel! Every year we set goals, make plans and craft visions to perform better than the year before, whether it is in relationships, financially, in our careers or even physically. This year, I have decided to begin simple! I crafted two small goals that could be completed in less than one month’s time, but the effects would benefit far after completion, or should I say, inauguration.

Transitions of Care
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Chronic Wounds: A Case Manager’s Challenge in the Transition from Acute to Community-Based Care

BY RON BILLANO ORDONA, DNP, FNP-BC, GS-C, WCC
In an article I wrote for Nursing Clinics of America, I highlighted the critical role of effective care transitions for chronic wound patients, emphasizing the need for robust communication between acute, skilled nursing and community-based care settings. By focusing on nurse and nurse practitioner (NP)-led community-based initiatives and strategies that reduce hospital readmissions, I am advocating for comprehensive discharge planning and sustained follow-up care.

Rural Health
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Enhancing Rural Healthcare in Illinois: A Comprehensive Strategy by the Illinois Nurses Foundation

BY SUSAN Y. SWART, EDD, MS, RN, CAE
The Illinois Nurses Foundation is spearheading a transformative initiative to address the critical healthcare disparities that pervade rural areas in Illinois. By launching the Rural Workforce Development Nurse Scholarship and preparing to introduce a separate retention program in early 2025, the foundation aims to create a robust and sustainable rural healthcare workforce.

Social Determinants of Health
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Doing the Nitty-Gritty–Using SDOH

BY PEGGY A. ROSSI, BSN, MPA
As someone who has done or taught discharge planning for many years, one key component that holds true for me today is that when discharge planning assessments are performed, especially on those very complex cases, they must be very comprehensive.

Rural Health
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Transitions of Care for Patients in Rural Communities

BY NANCY SKINNER, RN, CCM, CMGT-BC, ACM-RN, CMCN, FCM
Regardless of governmental data and descriptions, it is my belief that the term rural cannot be quantified by a single descriptor, zip code, town or area. Instead, it is important to realize that for our patients a rural residence represents a symphony of challenges and barriers that might impact their ability to achieve the highest level of health and function through and across the healthcare continuum.

Rural Health
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Is Living Rural Considered a Health Risk?

BY GARY WOLFE, RN, CCM, FCM
Have you ever given any thought to the idea that where you live may have a direct impact on your health outcomes? Probably not, because I don’t think many people think about their health and where they are living until they have significant health concerns or are retiring. People choose where they live based on a variety of issues: family, employment, economic factors, opportunities, education, etc. This article will examine the impact living in a rural area has on your health outcomes and some of the influencing factors.

Association News
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Elevating Case Management Through Education, Networking and Community: CMSA in 2025

In a profession as dynamic and vital as case management, staying informed, connected and prepared is key to providing exceptional care. Whether it’s fostering meaningful connections with peers, building advanced skills or exploring innovative practices, the Case Management Society of America (CMSA) continues to empower case managers to thrive in their careers and make a lasting impact.

Elder Care
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Program for All-Inclusive Care for the Elderly

BY LISA SIMMONS-FIELDS, DNP, MSA, RN, CCM, CPHQ, FCM, AND ANNE LEWIS
Case managers working with aging populations need to be able to link patients with resources in the community. The Program of All-Inclusive Care for the Elderly (PACE®) is a comprehensive, high-touch provider-based health plan for frail, complex individuals who require a nursing home level of care.

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