Reducing Recurrence and Complications Related to Clostridioides difficile Infection: A Panel Discussion Summary.

Background: The Centers for Disease Control and Prevention identifies Clostridioides difficile infection (CDI) as an urgent threat to people and health care systems. CDI leads to high health care utilizations and results in significantly reduced quality of life for patients. The high burden of disease is seen across all health care settings, outside of the hospital, in the community, and in younger people.

Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.

Purpose/objectives: Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF).

Two useful tools: to improve patient engagement and transition from the hospital.

We use an Internet-based health assessment and feedback system to examine the range of needs and diverse experiences of 520 hospitalized adults in transition and the factors most strongly associated with their self-reported health confidence. Our results strongly suggest that patient engagement prior to admission and the quality of care coordination and communication during hospitalization can greatly enhance successful transition from the hospital back to the community. Hospitals are complex institutions.

Practices to improve transitions of care: a national perspective.

Improving transitions of care has significant importance to our health care system. While care transitions has been studied and researched by many individuals over the past 20 years, more work is needed to further improve the process. Those beginning to focus on transitions need not begin from scratch, but can use information and research from national and regional collaborative models, as well as other tools and resources to enhance the quality of transitions programs.

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators.

Objective: This article describes an innovative integrated approach to case management using a standardized complexity assessment grid and communication tool, which is designed to identify barriers to improvement in 4 domains: biological, psychological, social, and health system; to create and implement holistic care plans based on "anchored barriers; and to document ongoing targeted outcomes.

Practice Settings: Adult and pediatric case and disease managers working for hospitals or clinics, health care delivery systems, general medical health plans, care management vendors, government agencies, and employers can effectively employ integrated case management procedures.

Integrated Case Management: Integrated case management augments traditional care coordination by allowing trained medical or mental health managers to assist with cross-disciplinary barriers without handoffs; to connect multidomain barriers to mutually agreed-upon care plan goals and activities; and to measure clinical, functional, fiscal, quality of life, and satisfaction outcomes as a part of the management process, especially in high-cost, complex patients.

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators.

The 5% of patients using 50% of health resources commonly have interacting and persistent multimorbid illnesses; concurrent mental health problems; impaired social networks; and/or difficulties in accessing care through the health system. To improve outcomes in these patients, it is necessary to overcome clinical and nonclinical barriers that lead to poor health, treatment resistance, high health care cost, and disability. This article describes an innovative complexity-based and outcome-oriented approach using integrated case management.

The impact of CMSA's case management adherence guidelines and guidelines training on case manager-reported behavior change.

Purpose/objectives: The Case Management Society of America (CMSA) developed evidence-based guidelines (Case Management Adherence Guidelines, CMAG) for case managers to support increased efficacy of case managers in helping patients become more adherent to medication regimens. The effort was in response to documented high levels of nonadherence, and evidence demonstrating that lack of adherence negatively impacts patient health status. The CMSA engaged in a massive training program to support case manager adoption of the CMAG tools and approaches to improve patient knowledge and motivation.