Health Confidence: A Novel Approach to Patient Education to Reduce Readmissions

We will share a successful project of interdisciplinary collaboration amongst RN Case Managers, Social Workers, Pharmacists, Physical Therapy, Respiratory Therapy, Nursing Leadership, Hospital Leadership, and Physicians at a mid-size community teaching medical center, aimed at increasing the patient’s perceived confidence in managing themselves and their chronic condition(s) independently. Our intervention is a complement to traditional patient education strategies and incorporates different adult learning styles, promotes interdisciplinary cooperation, addresses social determinants of health and optimizes the coordination of care for patients with chronic medical conditions. Leveraging the knowledge base across the interprofessional team and addressing identified patient education needs, we strive to “bring it all together” before the patient is discharged from our acute facility and facilitate an interactive patient education experience.

Learner Outcomes:

At the end of the presentation, the learner will be able to:

  • Evaluate the needs assessment completed to identify the gaps in patient education from the patient’s perspective.
  • Describe the journey to developing the program and roles and functions of all the team members involved in the interactive patient education experience.
  • Identify through actual case studies how the team manages the collaboration and includes all members of the inter-professional team including the patients and their families, to address educational gaps and increase patient health confidence in managing their chronic conditions independently post discharge; contributing to decrease in utilization, readmissions and length of stay.

This content will apply to the following Ethical Principles (Commission for Case Manager Certification 2015) Principles.  Board certified Case Managers will:

  • Principle 1 place the public interest above their own at all times.
  • Principle 4 act with integrity and fidelity with clients and others.
  • Principle 5 maintain their competency at a level that ensures their clients will receive the highest quality of service

This content will apply to the following Ethical Principles and Standards from the Code of Ethics (National Association of Social Workers, 2017). 

  • Ethical Principles:
    • Service 
    • Social Justice
    • Dignity and Worth of the Person
    • Importance of human relationships
    • Competence
  • Ethical Standards:
    • 1: Social Workers’ Ethical Responsibilities to Clients
      • 1.01 Commitment to Clients
      • 1.03 Informed Consent
    • 2: Social Workers’ Ethical Responsibilities to Colleagues
      • 2.03 Interdisciplinary Collaborations



Colleen MorleyColleen Morley DNP, RN, CMCN ACM-RN is the Director of Case Management Services for West Suburban Medical Center in Oak Park, IL and Westlake Hospital in Melrose Park, IL under the Tenet System.

Colleen has over 19 years of nursing experience. Her clinical specialties include Med/Surg, Oncology and Pediatric Nursing.  Her passions in nursing include the promotion of professional development and continuing education and studying the readmission issue to develop solution programs.

She is active with CMSA Chicago; currently serving as President-Elect for 2017-19 and has been on several national-level committees for CMSA (Education, Awards), ACMA (Membership) and AAMCN (Education and Membership). Additionally, she currently holds the position of Director on the ANA-IL Board of Directors, serving as Legislative Committee Chair and PAC Trustee.