Put an End to Missed Opportunities The ongoing transformation of America's health care system is bringing disruption in every sector of our industry. Hospital case management programs are similarly undergoing dramatic changes as care coordination for our most vulnerable patients becomes the focus of many hospital case management programs. As a result, case management leaders and human resource directors are disrupting legacy assumptions and expanding eligibility for the role of the hospital case manager.

The Practice of Hospital Case Management: A White Paper: Hospital Case Management: Past, Present and Future No abstract available

The Practice of Hospital Case Management: A White Paper—Hospital Case Management: Past, Present and Future No abstract available

Improving Care Transitions to Drive Patient Outcomes: The Triple Aim Meets the Four Pillars Purpose: The purpose of this article is to examine how case managers can support positive outcomes during care transitions by focusing on the goals of the Triple Aim (D. Berwick, T. Nolan, & J. Whittington, 2008) and Coleman's Four Pillars (E. Coleman, C. Parry, S. Chalmers, & S. Min, 2006). Case managers can play a pivotal role to ensure high-quality transitions by assessing patients and identifying those who are at high risk; coordinating care and services among providers and settings; reconciling medications; and facilitating education of patients and their support systems to improve self-management. These activities are congruent with an underlying value of case management as defined by the Code of Professional Conduct for Case Managers: “improving client [i.e., patient] health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation” (Commission for Case Manager Certification [CCMC], Code, Rev. 2015). Case Management Primary Practice Settings: Case managers across health or human services must assess for, identify, and understand the vulnerability of patients during care transitions and must adopt best practices to support successful care transitions. This includes case managers in acute care, primary care, rehabilitation, home health, community-based, and other settings. Implications for Case Management Practice: Two frameworks that support care transitions are the Triple Aim of improving the individual's experience of care, advancing the health of populations, and reducing the costs of care (D. Berwick, T. Nolan, & J. Whittington, 2008), and Coleman's “Four Pillars” of care transition activities of medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (E. Coleman, C. Parry, S. Chalmers, & S. Min, 2006). From a case management perspective, these approaches and their goals are interrelated. As an advocate for the individual and at the hub of the care team, the professional case manager engages in important activities such as facilitating communication across multiple providers and care settings, arranging “warm handoffs,” undertaking medication reconciliation, and engaging in follow-up, particularly with high-risk patients. To support successful transitions of care, case managers must adopt best practices and advocate within their organizations for systematic approaches to care transitions to improve outcomes.

Improving Care Transitions to Drive Patient Outcomes: The Triple Aim Meets the Four Pillars No abstract available

Time Contribution of Social Workers in Care Management: Value for Older Adults Purpose of the Study: The purpose of this study was to examine the time contribution of social workers in delivering AIMS (Ambulatory Integration of the Medical and Social), a care management protocol designed to address patients' nonmedical needs, and the association of time contribution with patients' depression outcomes. Primary Practice Setting: The study was conducted in 6 primary care provider clinics housed in a large, urban academic medical center located in the Midwestern United States. Methodology and Sample: A longitudinal, quasi-experimental study employing survey procedures and a retrospective review of patient records was conducted. The study included 340 patients 50 years and older with unmet nonmedical needs. Half of the patients received AIMS, which was delivered by social workers. The other half received usual care (UC), which was delivered by other health care providers. Results: Chi-square analysis and independent-samples t tests were performed to compare time spent addressing nonmedical needs with differences in patients' depression levels at 6 months postenrollment. The findings reveal that social workers spend significantly more time with patients than UC providers addressing patients' nonmedical needs (p < .0001). At 6 months postintervention, reduced levels of depression were observed for AIMS patients when compared with UC patients (p = .026). Implications for Care Management Practice: Including social workers as part of health care teams is valuable. Time spent with patients and engaging in care management activities to support patients' needs is linked with positive health outcomes. Given the benefits of care management, opportunities for reimbursement are enhanced.

Ambition Is a Fabulous Word No abstract available

In Memoriam: Margaret (Peggy) Leonard, MS, RN-BC, FNP No abstract available

Social Work: The Power of Case Management's Interprofessional Workforce No abstract available

A Keen Eye Avoids Plagiarism: A Cautionary Tale No abstract available