Hospital to Community-Based Care Models

Despite advances in care coordination and utilization management, many Medicaid/Medicare populations continue to experience poor outcomes related to fragmented care transitions and unmet social needs. Case managers (CMs) are often expected to address these gaps without practical, community-based tools that extend beyond traditional clinical settings.

As healthcare systems continue to shift toward value-based care, CMs must manage complex medical needs alongside social drivers that influence outcomes across the continuum. However, many care delivery models still struggle to effectively bridge the gap between hospital discharge, outpatient follow-up and sustained community-based support.

This session presents an innovative, scalable, case manager-led community-based education and care approach designed to improve continuity and strengthen outcomes in underserved populations. Drawing on more than 30 years of nursing and case management leadership experience, including Medicaid and Medicare Advantage population health program, the presenter will share real-world case studies that demonstrate how integrating health education, care coordination and social resource navigation in community settings can improve outcomes, enhance advocacy and reduce avoidable utilization.

Attendees will explore a structured framework grounded in evidence-based CM principles, including the Care Transitions Model, screening for social drivers of health and whole-person, community education strategies. The session will demonstrate how tools such as standardized assessments, referral workflows, health literacy-focused education and closed-loop follow-up can be implemented in community settings and aligned with value-based care priorities.

Participants will gain practical strategies to expand case management impact through partnerships with community organizations, interdisciplinary collaboration and advocacy-driven interventions beyond traditional care settings. This session highlights the evolving role of the certified case manager as a systems thinker, advocate and innovator positioned to lead care transformation across the full continuum of care.