Care Coordination and Transition Management: Introduction
American Academy of Ambulatory Care Nursing (AAACN)
The need for care coordination and management of transitions between patient-centered medical home providers, outpatient, and community settings, including the Accountable Care Organization, is often overlooked and episodic, and accountability for coordinating care and managing transitions between providers and services is lacking. AAACN recognized the potential of the RN to contribute to enhanced quality, cost-effectiveness, and access to care in ambulatory settings and supported the creation of an evidence-based CCTM Core Curriculum and Online Education Modules developed by experts representing practice, education, and research across the United States. This module discusses the RN-CCTM Model, defines care coordination and transition management, identifies the nine dimensions of CCTM and the technologies that provide decision support and information systems for all dimensions, and describes the competencies necessary to support the role of the RN-CCTM. There will be 12 education modules to follow as part of the CCTM Course. Nine will cover the evidence-based dimensions, two will cover the technologies (i.e., Informatics Nursing Practice and Telehealth Nursing Practice), and one will be dedicated to the transition from acute care to ambulatory care and the critical nature of hand-offs in ensuring patient safety and quality of care. Purpose: The purpose of this activity is to enable the learner to identify key components of the CCTM Core Curriculum. Requirements for Successful Completion: 1. Read the PDF handout which is the chapter of the CCTM Core Curriculum that corresponds with this activity. 2. Complete the activity in its entirety. 3. Complete the online CNE evaluation. Faculty, Planners and Authors Conflict of Interest Disclosure: Faculty, planners, and authors have no disclosures to declare. Commercial Support and Sponsorship: No commercial support or sponsorship declared.
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      Care Coordination and Transition Management: Introduction