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Membership Continuing Education
Achieve Optimal Outcomes with a Patient-Centric Care Coordination and Discharge Planning Model

Publication Date: 3/12/2024


Length: 60 minutes, 49 seconds

Content Level: 1 Advanced, General CE

Abstract
Uncoordinated, fragmented patient discharges can lead to poor patient outcomes and costly readmissions. This presentation shares how a large integrated delivery and finance system explored the allocation of resources and redesigned a more efficient system approach to clinical care coordination and discharge planning. Discussion of model components includes a new executive leadership structure, a single point of contact responsible for discharge planning, a cascading clinical ladder, and alignment for care managers, social workers, post-acute liaisons and transition coordinators.

Learning Objectives
1. Assess ways to evaluate hospital resources to better coordinate care and discharge planning.
2. Describe how existing roles can be reimagined and restructured to better meet the needs of the patient and their family.
3. Identify ways the role of the social worker can be elevated to improve outcomes in the in-patient, acute care setting.
4. Demonstrate the importance of creating a single point of contact for patients during the discharge process.

Speakers:
Jennifer Hall, MSN, RN, CCM, ACM-RN | Senior Director, Care Management | UPMC

Jennifer Hall is a registered nurse, certified and accredited case manager who has held progressive leadership roles within care management at UPMC for the past 17 years. She began her UPMC career as a nurse at UPMC Passavant and transitioned to care management in 2005 at Magee Women’s Hospital. She was promoted to Manager of Health Management at Magee in 2007, where she served for several years before taking a role as Director of the Care Management Department at UPMC Passavant in 2012. Most recently, she was promoted to Senior Director for Clinical Care Coordination and Discharge Planning for UPMC. In addition to her work at UPMC, Jennifer has served in various roles with the ACMA Western Pennsylvania Chapter, including Treasurer, President Elect, President and since 2020, Nominations Committee/Vendor Chair.

Dr. Amanda Lenhard, MD | Senior Medical Director, Clinical Care Coordination and Discharge Planning | UPMC

Dr. Amanda Lenhard completed her undergraduate education at Texas A&M University and earned her medical degree from Case Western Reserve University School of Medicine. Lenhard joined UPMC in December 2020 as Chief of the Department of Medicine at UPMC Shadyside, Department of Medicine lead for Quality and Chief of the Section of Hospital Medicine. Prior to joining UPMC, she served as Chief of Staff, Chief of Hospital Medicine, and Chief of Quality for the Department of Medicine at the University of Toledo Medical Center and has held positions in management, utilization review and physician advising. She is an active and proud member of the UPMC Health Services Division Throughput Excellence Committee and the UPMC Health Services Division Throughput Hospital Consultant Team. In May 2022, Dr. Lenhard accepted the role of Senior Medical Director, Clinical Care Coordination and Discharge Planning for the Health Services.

Keywords: discharge planning, social work, acute care

Achieve Optimal Outcomes with a Patient-Centric Care Coordination and Discharge Planning Model

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