Departments: The HeartBeat of Case ManagementCase Managers A Key to Reducing ReadmissionsEllsworth, Jennifer L. MSWAuthor Information Jennifer L. Ellsworth, MSW, is a clinical social worker within the palliative care team at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. Throughout her social work career, she has focused on the geriatric population, transitions of care, and community support. Before her position at Dartmouth–Hitchcock Medical Center, she developed and implemented a $3.2-million CMS Care Transitions Grant that funded a hospital—wide transitions of care program. Jennifer's contribution to this column reminds us of how we manage and support our patients individually while focusing on “key indicators,” such as readmissions. Address correspondence to Jennifer L. Ellsworth, MSW, DHMC Office of Care Management, 1 Medical Center Drive, Lebanon, NH 03756 (Jennifer.L.Ellsworth@hitchcock.org). The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Mindy Owen at: firstname.lastname@example.org or Teresa Treiger at: Teri.email@example.com The author reports no conflicts of interest. Professional Case Management: May/June 2015 - Volume 20 - Issue 3 - p 147-149 doi: 10.1097/NCM.0000000000000092 Buy Metrics Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.