This module will introduce the collaborative professional role Case Managers perform and the necessary case management strategies to improve transitional care for high-risk patient populations. Focus is on needs assessments, brokerage and monitoring of health care services and resources, comprehensive assessments, care coordination practices, proactive discharge planning, patient/family advocacy, and the provision of appropriate transitional care interventions. These interventions include culturally and linguistically appropriate education, supportive, and counseling strategies to enhance self-care management and empower patient/care-giver to manage their chronic illness and symptoms management
