Beyond the Discharge: Reducing Unplanned Readmissions Through Collaborative Care Transitions

Learning Objectives:

• Describe key clinical, social, and operational drivers contributing to 30-day unplanned readmissions.

• Explain how multidisciplinary care transition strategies can improve post-discharge continuity and reduce avoidable utilization.

• Identify practical approaches to risk stratification, follow-up coordination, community linkage, and post-discharge outreach that can 
  be adapted in case management practice.

Special Guest Speakers:

Eddie Eabisa, MBA, is the Manager of the Transitions of Care Department at UC Davis Health, where he leads system-level initiatives 
focused on improving care transitions, reducing avoidable readmissions, and supporting hospital capacity management. He holds an MBA 
in Healthcare Management and a Bachelor’s degree in Applied Mathematics and Statistics. Since joining UC Davis Health in 2015, Eddie 
has played a key role in advancing quality improvement efforts across the health system. His work includes leading multidisciplinary strategies 
to improve discharge coordination, strengthen post-discharge support, expand care navigation, enhance skilled nursing facility partnerships, 
and develop data-informed interventions to support high-risk and complex patient populations. Eddie brings extensive experience in clinical
process improvement, workflow redesign, care coordination, and performance monitoring. He is especially focused on building sustainable,
enterprise-level solutions that improve patient outcomes, reduce unnecessary hospital utilization, and strengthen collaboration across inpatient, 
ambulatory, emergency department, and community-based care teams. Through his leadership, Eddie continues to support patient-centered care 
delivery while advancing operational excellence across the continuum of care.

Vanessa McElroy, MSN ACM-RN PHN IQCI, is the Director of Case Management, Transitions of Care, and Population Health Care Management
at UC Davis Health, a leading academic health system and Level I Trauma Center in Sacramento, California. With a Bachelor of Science in Nursing 
and a Master of Science in Health Nursing Informatics, she brings a unique blend of clinical expertise, operational leadership, and informatics innovation
to advancing patient care across the continuum. In her role, Vanessa provides strategic oversight for Clinical Case Management, Outpatient 
Comprehensive Care Management, Transitions of Care, Clinical Social Work, Home Care Services, Chaplain Services, and Managed Care Utilization. 
She leads health system initiatives that support organizational goals related to quality, patient experience, value-based care, health equity, and financial
stewardship. A recognized leader in care coordination and population health, Vanessa has spearheaded programs focused on reducing avoidable 
readmissions, improving transitions of care, and addressing social drivers of health (SDOH). Her work has expanded services for patients with complex 
medical and social needs, strengthening connections to community resources and support services that improve access, outcomes, and overall well-being. 

Provider approved by the California Board of Registered Nursing, Provider Number CEP 15522, for 1.0 contact hours, CCM PENDING