Creating individualized care plans for high-utilizer patients involves addressing their unique needs, identifying barriers to care, and bridging gaps in healthcare delivery through a collaborative and empathetic approach. This process integrates input from Diversity, Equity, and Inclusion (DEI) champions and emphasizes a holistic strategy that considers medical, social, and psychological needs. By fostering collaboration among a multidisciplinary team, these efforts aim to ensure comprehensive and patient-centered care.
Presentation topics include:
- Utilize risk stratification and data analysis to determine the correlation between high utilizer patients and avoidable readmission rates and cost of utilization.
- Develop individualized care plans that encompass medical, social, and psychological aspects, and input from DEI champions resulting in improved health outcomes and reduced hospital readmissions.
- Integrate tools and enhancements in the Electronic Medical Record (EMR) system to facilitate the creation of effective and efficient visualizations and easy access to care coordination notes and care plans.
- Identify common barriers to effectively adapt the discussed framework and strategies.
Register via GoToWebinar.
Wednesday, Feb 19, 2025: 11:00 a.m.- noon (PT)

Vanessa McElroy, RN
Director of Care Management, Transitions of Care and Population Health Care Management
UC Davis Health System
Vanessa McElroy obtained her bachelor’s degree in science nursing from California State University Chico and completed her master’s degree in health nursing informatics from Grand Canyon University, enabling her to seamlessly blend her knowledge of health care with cutting-edge informatics solutions. She is currently serving as the Director of Care Management, Transitions of Care and Population Health Care Management at UC Davis Health System, a renowned Level 1 Trauma and Academic Hospital in Sacramento, CA where she oversees multiple departments, including Clinical Case Management, Outpatient Comprehensive Care Management, Transitions of Care, Clinical Social Work, Chaplain Services and Managed Care and Utilization Management. Over the past four years, she has spearheaded the development of programs under Transition of Care and established it as a department, implementing innovative strategies to optimize patient outcomes and streamline health care delivery.
HQI is an approved continuing education (CE) provider by the California Board of Registered Nursing and will provide CHPSO members an opportunity to earn CEs. Provider Number CEP16793 for 1 contact hour.
Please contact CHPSO at info@chpso.org if you have any questions.