Session ID: 

Optimizing Care Transitions Across the Continuum

12:00pm - 1:00pm Friday, February 15
Orlando - Orange County Convention Center


Implementing a strategy to address transitions of care across a large, integrated health network presents many challenges. Increased pressure to improve utilization rates along with new Transitional Care Management billing opportunities has incentivized health systems to find innovative, cost-efficient ways to ensure transitions occur safely and effectively. One large teaching hospital and health system prioritized a strategy to improve care provided to patients after being discharged. This session will discuss a two-fold approach to a cost-efficient model to address this strategy. First, a centralized Transition of Care call center was developed employing Registered Nurses and Medical Assistants who place calls to patients post-discharge; this model works on behalf of the primary care providers (PCPs). Secondly, the workflow for this process was streamlined using various functions within the EHR allowing for an increase in staff productivity.

Learning Objectives: 

  • Recognize the impact a care transition strategy has on patient outcomes
  • Identify how improving EHR efficiencies positively impacts staff productivity
  • Describe the financial impact of a centralized model on the management of care transitions


Healthcare Data Analyst Lead,
Lehigh Valley Health Network
Manager, Population Health,
Lehigh Valley Health Network


Chief Quality, Chief Clin Transformation Officer
Nurse, CNO, CNIO
Population Health Management Professional