Case Management Leadership in Transitions of Care

The CM role in transitions of care is as a leader for the healthcare team… who is not only responsible for the Plan of Care (POC) but for the transition to the next level of care and into the most appropriate and agreed upon setting. Patients today present as complex, medically, psyche-socially, and many times with a variety of limited resources, all which need to be assessed and incorporated into an effective and comprehensive POC …today …tomorrow and into the future.

At the end of the presentation, the learner is able to:

  1. Discuss the leadership role they play in the development of a transition of care plan.
  2. Identify management tools designed to assist in developing a comprehensive assessment and transition of care plan.
  3. Describe the importance of the multi-disciplinary team approach and the improved outcomes delivered.

This applies to Principle 2 of the CCMC Code of Professional Conduct – Board Certified Case Managers (CCMs) will respect the rights and inherent dignity of all their clients and Principle 4 – Board Certified Case Managers (CCMs) will act with integrity and fidelity with clients and others.


Mindy Owen RN, CRRN, CCM, began her career in healthcare as a critical care specialist in neurosurgery and rehabilitation.  She spent 3 years as the charge nurse of a Neuro ICU and the step-down unit at Milwaukee County Medical Complex.  She then joined the team that designed, developed and implemented an SCI-TBI rehabilitation program affiliated with Wesley Regional Medical Center in Wichita, Kansas.  Mindy was instrumental in preparing the program for both CARF and JACHO accreditation, as well as founding the Kansas Chapter of the ARN and serving on the National Board of the Association of Rehabilitation Nurses during her tenure as Program Director.

Her case management career began as the Midwest Regional Director of CM for Intracorp- a leader in disability, UR and CM services nationwide.  She was asked to be one of the Founding Board members of CMSA, helping to establish the organization and becoming its second President. During this time, the definition, standards of practice, and CM guidelines were developed.