Skip to main content

Transitional Care: Social Determinants of Health

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

Description and CE information:
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.

Learning 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 specific area of practice
Credit Information:
The Commission for Case Manager Certification (CCMC) is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.

This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. The course is approved for 1 CE contact hour(s). Activity code and Approval number will be awarded on your certificate of completion.

The Commission for Case Manager Certification is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers

All planners and speakers have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

Commercial Support or Non-Commercial Sponsorship:
There is no commercial support for this activity. The planners and faculty have no relevant relationships to disclose.

Expiration date: 6/1