Transitional Care: Social Determinants of Health (Toni Heer, MS, CNS, RN, CMC, CCCTM)

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Description

Moving beyond traditional, strictly medical determinations, providers are looking to provide unique, targeted interventions for both high-risk population subsets and individual clients, often through community-based care initiatives. Quality transitional care is particularly important to obtain optimal outcomes in the care of clients who are at risk for potentially preventable 30-day readmissions. This presentation will discuss how the Intensive Transitions Team has provided innovative, patient-centered care since 2015, explore an innovative model of transitional care and discuss the benefits of integrating a community-based organization with a hospital system or primary care practice.

Learner Outcomes

Differentiate and explain two discreet differences between hospital-based case management and Transitional Care case management
Explain two practice implications addressing the impact of social determinants of health
Identify 2-3 opportunities to incorporate SDOH Z-Codes into a specific area of practice

Contributors

Toni Heer, MS, CNS, RN, CMC, CCCTM

Toni Heer is a caring patient advocate, committed to providing equitable care to vulnerable populations. Provider of care that is respectful of and responsive to patient preferences and values and delivered beyond the bedside, across the care continuum. Toni Heer is particularly interested in social determinants of health, innovative care strategies and work to promote integrating community based organizations into healthcare. Toni is an active Board member for local Meals on Wheels, and our Boards healthcare taskforce. Toni has been employed at Upstate since March 2000, she is married and is the mother of a 26 year old son. Additionally, in her spare time Toni works on a 1400 acre crop farm with her husband, and enjoy outdoor activities such as camping, hiking, and horseback riding. Toni is interested in integrated health care opportunities and hope to become certified as an equine psycho therapist and assisting individuals with any level of disability to find improved sense of wellness through equine assisted therapy.