President's Message
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Welcome, 2024!

BY JANET COULTER, MSN, MS, RN, CCM, FCM
I hope everyone rang in the new year with great expectations and realistic resolutions! A new year presents a new beginning and the possibility of exciting adventures and boundless opportunities.

Transitions of Care
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A Road Less Traveled: Bridge to Home

BY JENNIFER CLINE, PT, DHSC, MS, AND SHONA METCALF, RN, BSN, MSN, CCM, IQCI
Carolinas Medical Center (CMC) in Charlotte, North Carolina, a facility of Advocate Health, has a Bridge to Home (BTH) program, which serves unfunded or underfunded patients by giving them two to three hours of therapy daily for approximately two weeks.

Continuum of Care
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Patient Advocates: A Crucial Piece of the Elder Care Puzzle

BY JENNIFER HALLORAN, PhD, BCPA
As case managers, we are all too aware of the myriad problems with our current healthcare system. One of the most intractable issues, particularly for elders, involves “frequent flyers,” patients who are admitted to the ED or hospital on a revolving basis. Despite the implementation of telephone-based follow-ups and other forms of tracking, this problem has not budged.

Readmissions
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How Home Care Impacts Hospital Readmission Rates

BY DANA TAYLOR, LCSW AND SYLVIA TREIN
Beginning in October of 2012, the Social Security Act established standards for the Hospital Readmissions Reduction Program (HRRP) in an effort to measure and increase the quality of care at hospitals across the country. The 21st Century Cures Act of 2019 further refined the process, where hospitals with comparable numbers of patients on Medicare and Medicaid could be measured against each other.

Best Practices
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Using Research to Advocate for Best Practices

BY KERRI WIZNER, MPH, CPH, AND KEEMIA VAGHEF, PhD
Managing injured or ill working-age people can be complicated when cases have co-occurring conditions or non-diagnostic factors (like the social determinants of health) driving people toward poor recovery outcomes. These complexities consume considerable time for case managers and can lead to longer recoveries, affecting the patient’s mental health and self-identity.

WORKFORCE
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Generational Diversity in the Workplace

BY JANET S. COULTER, MSN, MS, RN, CCM, FCM, AND, MARYANN OTT, BSN, RN, CCM, CPC
Leading a generationally diverse workforce is challenging. Effective leaders understand that each generation brings unique strengths, characteristics, values and challenges to the workplace.

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