Case Management

Navigating the journey from hospital to healing

Fact checked by Shannon Sparks

Nobody goes into the hospital hoping to leave and be hospitalized again. Yet, nearly 1 in 5 Medicare patients reenters the hospital within 30 days of discharge, according to the Centers for Medicare and Medicaid Services.

This costly and often-preventable outcome pushed hospitals nationwide to overhaul how they manage patient transitions. At the heart of this evolution is case management — the modern, team-based successor to traditional discharge planning. Case management teams guide patients through the critical shift from hospital to home, rehab, or long-term care. The healing that happens after a patient leaves the hospital is vital to reducing readmissions and improving outcomes.

“We start planning for discharge, honestly, upon admission,” says Jennifer Dominow, a registered nurse who leads the case management team at Loyola Medicine. Within 24 to 48 hours of admission, an interdisciplinary team of nurses and social workers assesses each patient’s clinical and social needs, and medical history. At the medical center, about half of patients return home, while the remainder require skilled nursing, acute rehab, or long-term acute care. As a major academic medical center with a Level-I trauma designation, Loyola often manages complex discharges.

In recent years, hospitals have increasingly invested in technology and predictive analytics to support case managers. These tools help prioritize high-risk patients early in their stay by analyzing vast amounts of electronic health record (EHR) data — including prior hospitalizations, diagnoses, lab results, medication adherence, and social determinants of health. This data-driven approach generates real-time risk scores, enabling case managers to act sooner and more effectively to reduce preventable readmissions and streamline the discharge process.

“Our main job is to provide a safe discharge to the appropriate level of care,” Dominow says. This involves building relationships with community facilities and reviewing their quality metrics. Still, she adds, “We empower the patient and family to make informed decisions.” Her team offers facility options based on medical need, insurance, and patient preferences, encouraging families to visit potential sites. 

Even in challenging cases — such as patients who are homeless or undocumented — no one is discharged without a destination. Loyola’s home-first philosophy aims to return patients to their pre-hospital condition whenever possible. Social workers on the team coordinate with housing agencies, shelters, and community-based organizations to ensure the appropriate resources are in place before discharge.

From discharge planning to case management

Traditional discharge planning focused on logistical tasks, such as arranging transportation or providing home care instructions. But as post-discharge needs became more complex, the role evolved. Case management now involves coordinated, interdisciplinary planning.

“Case managers are not just ‘discharge planners,’” says Colleen Morley, DNP, immediate past-president of the Case Management Society of America’s national board of directors and associate chief clinical operations officer for continuum of care at UI Health. “We are licensed professionals who conduct initial patient assessments within 24 hours of admission and work with the entire care team, including the patient, family, and caregivers, to create interdisciplinary plans to meet patient needs.”

The 2014 IMPACT Act expanded the role of case managers by allowing them to present publicly reported facility metrics to patients. “Using Medicare.gov, case managers can walk patients through detailed facility ratings, examining health inspections, staffing, and quality measures,” Morley says.

Impact on readmission rates

Researchers have linked case management to significant reductions in hospital readmissions. A study in The BMJ  highlighted Kaiser Permanente Northern California’s Transitions Program, which used predictive modeling and case management to successfully lower readmissions by 10% without increasing mortality.

In Illinois, the Department of Public Health collects hospital discharge data statewide. An analysis by the Illinois Institute for Rural Affairs found that rural counties achieved greater reductions in 30-day readmission rates between 2007 and 2022 compared to metropolitan areas, suggesting that more focused discharge planning and follow-up may be key in these regions. Other regional efforts, such as telehealth follow-up programs and pharmacist-led medication reviews, also support patients during the critical post-discharge period.

Nationally, the Agency for Healthcare Research and Quality developed a toolkit that has helped hospitals reduce readmissions by enhancing education, medication reconciliation, and care coordination. Additional strategies that support successful case management include:

     • Predictive analytics to identify patients at highest risk of readmission

     • Multidisciplinary care teams to create comprehensive discharge plans

     • Family and caregiver engagement, shown to reduce readmissions by up to 25%

     • Standardized discharge protocols to keep the process consistent so everyone involved knows what to expect

Patient discharge challenges

Despite the benefits of case management, several challenges remain. A 2022 study in Health Affairs found that communities with more primary care physicians and nursing home beds had lower 30-day hospital readmission rates. In contrast, areas with more home health agencies and nurse practitioners saw higher readmission rates — possibly due to fragmented care and high staff turnover.

Additional studies have shown that people with unmanaged chronic conditions or limited caregiver support have a higher risk for readmission. Socioeconomic factors such as lack of transportation, limited access to follow-up care, and medication affordability can also hinder recovery after discharge. Variability in post-acute care quality contributes to different outcomes across facilities and regions.

Hospitals and policymakers are increasingly looking at neighborhood-level data and patient-reported outcomes to better understand the barriers patients face after leaving the hospital. And efforts to reduce readmissions continue to focus on the areas with a proven track record: care coordination, discharge processes, and post-discharge support.

If you know you’re having a procedure or have multiple health conditions, start researching potential care facilities beforehand,” Morley says. “Don’t wait for a crisis moment to make these critical decisions. I’m 59 years old. If anything happened to me and I needed to go to a rehab, I can tell you exactly the rehabs that I have selected that are in my insurance plan.” 

Learning how the process works is step one.

Originally published in the Summer/Fall 2025 print issue.