Care Coordination and Transition Management: Between Acute Care and Ambulatory CareCE
American Academy of Ambulatory Care Nursing (AAACN)
Transitioning patients from one care setting to another and coordinating their care ensures health care continuity while avoiding preventable poor outcomes. While the process sounds simplistic, the reality is that as patients move from one level of care to another, among multiple providers and across settings, the process can derail and communication can break down. An engaged health care team working collaboratively with the patient, family, and caregivers can improve quality of care, patient satisfaction, and patient outcomes. The importance of integrating evidence-based practice guidelines into transitions of care along with the knowledge, skills, and attitudes of the RN in the CCTM role will be discussed. A patient scenario is used to illustrate how tools for transitioning from one level of care to another can be applied. Purpose Statement: The purpose of this activity is to enable the reader to understand the impact a mutually developed, implemented, and continuously evaluated transition of care plan has on quality of care, patient satisfaction, patient outcomes, and financial impact, and to understand the importance of integrating evidence-based practice guidelines into a transition of care plan. 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: Between Acute Care and Ambulatory Care