Map a patient's care journey from referral to discharge and identify points of avoidable delay.
Healthcare & Pharmaceutical Management
Case Management and Care Coordination Across the Patient Journey
Prepares case managers and coordinators to map the patient journey, prioritise caseloads and coordinate multidisciplinary teams so transitions between care settings happen without avoidable delay.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
Patients rarely experience care as a single episode; they move between primary care, specialists, hospital wards, rehabilitation and home support, and each handover is a point where information, responsibility or momentum can be lost. This course treats case management as the discipline that holds that journey together. Participants learn to map a patient's pathway from referral to discharge and beyond, identify where delay or duplication typically occurs, and build the coordination routines that close those gaps. The programme covers caseload prioritisation methods for case managers carrying mixed-acuity patients, structured discharge planning that starts at admission rather than the day before departure, and the multidisciplinary team meeting formats that keep clinicians, therapists and social care aligned. A dedicated module addresses long-term condition case management, including risk stratification and proactive contact models that keep patients out of avoidable emergency attendances. Throughout, the emphasis is on documentation that travels with the patient: care plans, transition summaries and shared goals that the next professional in the chain can act on immediately.
Expected Learning Outcomes
Prioritise a mixed-acuity caseload using a documented risk and urgency scoring method.
Design a discharge plan that begins at admission and names the criteria for a safe transition.
Chair a multidisciplinary team meeting that produces a shared, actioned care plan.
Build a proactive contact model for long-term condition patients that reduces avoidable admissions.
Draft a transition summary that carries clinical, functional and social information between settings.
Evaluate case management caseload outcomes using readmission, delay and goal-attainment measures.
Who Should Attend
Case managers and care coordinators handling mixed-acuity patient caseloads.
Discharge planning leads and ward-based transition of care coordinators.
Community and long-term condition nurses managing proactive patient contact.
Social workers participating in multidisciplinary discharge planning meetings.
Rehabilitation and allied health professionals coordinating post-acute care.
Health system leaders designing case management models across care settings.
Course Modules
Select any module to see its sessions and points.
01Mapping the Patient Journey and Coordination Gaps
2 sessions · 8 points
Session 1Journey Mapping from Referral to Discharge
- Construct a patient journey map that traces every handover between referral, admission and discharge.
- Identify the specific points in the journey where information, responsibility or momentum is typically lost.
- Distinguish delays caused by clinical decision-making from delays caused by coordination failure.
- Interview patients and families to capture their experience of transitions the journey map may miss.
Session 2Defining the Case Manager's Role and Scope
- Define the case manager's scope of authority relative to treating clinicians and social care teams.
- Distinguish case management models including brokerage, intensive and integrated approaches by patient need.
- Set caseload size and complexity limits based on acuity mix rather than patient count alone.
- Establish escalation routes for cases where coordination alone cannot resolve a clinical or social barrier.
02Caseload Prioritisation and Risk Stratification
2 sessions · 8 points
Session 1Scoring Urgency and Risk Across a Mixed Caseload
- Apply a documented risk and urgency scoring method to rank cases needing same-day attention.
- Combine clinical acuity, social vulnerability and prior admission history into a single prioritisation score.
- Rebalance a caseload when a case manager returns from leave or a colleague's caseload is redistributed.
- Set review frequency by risk tier so high-risk patients receive more frequent proactive contact.
Session 2Proactive Contact Models for Long-Term Conditions
- Design a proactive contact schedule for long-term condition patients based on risk stratification tiers.
- Build early-warning triggers from symptom, medication and self-reported data that prompt case manager contact.
- Coordinate proactive contact with primary care to avoid duplicated or conflicting patient outreach.
- Measure the effect of proactive contact on avoidable emergency attendances over a defined period.
03Discharge Planning and Care Transitions
2 sessions · 8 points
Session 1Discharge Planning from the Point of Admission
- Open a discharge plan at admission and name the clinical and functional criteria for a safe transition.
- Coordinate therapy, equipment and home support assessments early enough to avoid discharge-day delay.
- Identify discharge barriers related to housing, family support or ongoing treatment before they cause delay.
- Set an estimated discharge date and communicate it consistently across the multidisciplinary team.
Session 2Transition Summaries and Handover Quality
- Draft a transition summary that carries diagnosis, medication changes, functional status and outstanding actions.
- Confirm receipt and understanding of the transition summary with the receiving care provider before transfer.
- Design a follow-up contact within a defined window after transfer to catch early transition failures.
- Audit a sample of transition summaries against a documentation standard and report the gaps found.
04Multidisciplinary Coordination and Outcome Measurement
2 sessions · 8 points
Session 1Running Effective Multidisciplinary Team Meetings
- Structure a multidisciplinary team meeting agenda that produces decisions rather than status updates.
- Chair a meeting that surfaces disagreement between disciplines and resolves it against the patient's goals.
- Assign named actions and deadlines from each multidisciplinary meeting and track them to completion.
- Involve patients and families directly in goal-setting discussions rather than relaying decisions afterward.
Session 2Measuring Case Management Outcomes
- Select outcome measures for case management including readmission rate, delay days and goal attainment.
- Build a caseload dashboard that shows case managers where their patients sit against key milestones.
- Compare outcomes across case management models to identify which suits which patient population.
- Present case management outcome data to commissioners or executives in a format that supports investment decisions.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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