Transitional Care: Social Determinants of Health

Timeslot: Friday, March 13, 2020 - 11:00am to 12:00pm
Session Type: General Session
Room: Colorado Ballroom A - Convention Center Level 3


Moving beyond traditional, strictly medical determinations, providers are looking to provide unique, targeted interventions for both high-risk population subsets and individual clients, often through community-based care initiatives. Quality transitional care is particularly important to obtain optimal outcomes in the care of clients who are at risk for potentially preventable 30 day readmissions. This presentation will discuss how the Intensive Transitions Team has provided innovative, patient centered care since 2015, explore an innovative model of transitional care and discuss the benefits of integrating a community-based organization with a hospital system or primary care practice.

Learning Outcomes

  • Differentiate and explain two discreet differences between hospital-based case management and Transitional Care case management

  • Explain two practice implications addressing the impact of social determinants of health

  • Identify 2-3 opportunities to incorporate SDOH Z-Codes into specific area of practice