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Home > Webinars
Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a 60-minute webinar on April 6, 2011. Archive Version
Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a 60-minute webinar on April 6, 2011. Archive Version
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Through a growing number of community partnerships with skilled nursing facilities, the Care Coordination Network created by Summa Health System has been able to reduce hospital readmission rates and average length of stay for patients transferred to these SNFs...and has them well-positioned as they work toward development of an accountable care organization (ACO).

By identifying three key areas to improve care transitions between the hospital discharge and a SNF admission, Summa Health System developed a collaborative model of care for this next level of care among a network of privately owned, competing SNFs.

Listen to pre-conference comments from Carolyn Holder.

During Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a 60-minute webinar on April 6, 2011, now available as a training DVD, via On Demand Web access or as a CD-ROM, Carolyn Holder, manager of transitional care for Summa Health System and Michael Demagall, administrator, Bath Manor & Windsong Care Center, shared:

  • How to create a win-win for SNFs and hospitals to reduce readmission rates;
  • Three key areas that negatively impacted care transitions between Summas hospitals and SNFs in its community;
  • Strategies implemented by Summa to address the key hospital-to-SNF transition challenges;
  • How to develop a QI process that monitors transitions on an ongoing basis to identify weaknesses in the care transition process; and
  • How the partnership is being developed and enhanced as the hospital system works toward development of an ACO.

Have questions on our webinar and/or webinar formats? Visit our webinar FAQ.

You can listen to this program right in your office and enjoy significant savings no travel time or hassle; no hotel expenses. Its so convenient! Invite your staff members to gather around a conference table to listen to the CD, DVD or the On Demand version.


CEOs, medical directors, discharge planners, quality improvement executives, skilled nursing facility executives, business development and strategic planning directors and consultants.


Carolyn Holder
Before it could improve the transition, the network first had to look at what wasnt working.

Carolyn Holder, M.S.N., R. N., G.C.N.S.-B.C., is manager for transitional care for Summa Health System. Holder also works with the Summa Health Systems Care Coordination Network of 40 nursing facilities in the development of clinical tools and processes to improve care and transitions of care. Her transitional work encompasses, hospital processes, handoffs to nursing facilities, home care, leading an interdisciplinary collaboration with the Area Agency on Aging and work on transitional models. She is also serving as co-chair of the care model work team for Summa Health Systems efforts to develop an Accountable Care Organization.

Holder was the geriatrics clinical nurse specialist for Summa Health Systems original Acute Care for Elders (ACE) Unit from 1994-2001 and also served as co-investigator working with Dr. Steven Counsell in a randomized controlled trial of ACE applied to a community hospital setting published in Journal of the American Geriatrics Society 2000.

Holder has co-authored articles and done numerous presentations on ACE, has served as a consultant in the development of the multiple ACE models at Summa Health System, Summa Home Care, skilled facilities, a Medicare-managed care HMO and to other hospital systems implementing the ACE model.

Holder received her Bachelor of Science and Master of Science in Nursing from Kent State University. She is certified by the American Nurse Certification Center as a Clinical Nurse Specialist in Gerontology.

Michael Demagall

Michael Demagall, L.N.H.A., L.P.N., is administrator for Bath Manor and Windsong Care Center. In his current position as administrator, he manages a 150-bed skilled nursing facility (SNF,) as well as an 84-bed SNF and assisted living (AL) in Akron, Ohio. Additionally, he has special interests in transitions of care, case management, minimum data set (MDS) assessments, facility training and patient/family education. Demagall has extensive work experience in the areas of admissions, case management, Medicare and insurance benefits.

Since 1992, Demagall previously worked at Multi-Care Management starting as a charge nurse at one of their facilities. His job duties included direct care nursing, MDS assessments, admissions and marketing coordinator, and nurse case manager.

Demagall is the co-chair for Summa Health Systems Care Coordination Network and board member for Mature Service, Inc. of Akron, Ohio, and past president and current board member of University Hospitals Bedford Medical Centers Senior Network. He held a seat on Ohios case mix advisory group, and is an active participant in other various hospital and senior groups.

Demagall is a licensed practical nurse (LPN) from Marymount Hospital, Cleveland, Ohio and received his Bachelor in Healthcare Administration from American Intercontinental University.

Publication Date: April 6, 2011
Number of Pages: 60-minute webinar
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