Care Coordination and Transition Management: Patient-Centered Care PlanningCE
American Academy of Ambulatory Care Nursing (AAACN)
Patient- and family-centered care is essential in designing a plan of care. A pre-visit chart review and visit planning will be discussed, as will the need for performing a comprehensive needs assessment of the patient to appropriately develop a plan for interventions founded in evidence-based guidelines. The RN in the CCTM role recognizes the integral part patients, families, and caregivers have in ensuring the health and well-being of patients and is aware that engaging patients and their families in care plan development improves patient outcomes and increases patient and family satisfaction, restoration of dignity and control, and better management of resource allocation results. The ability to identify gaps in care, utilize motivational interviewing, and the importance of the multidisciplinary collaboration across the continuum of care will be addressed in this activity. Purpose Statement: The purpose of this activity is to enable the learner to demonstrate the ability to develop, implement, and provide ongoing management of a comprehensive plan of care based upon the individual patient’s values, preferences, and needs in partnership with the primary care provider and larger interdisciplinary care team. 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: Patient-Centered Care Planning