Care Coordination and Transition Management: Population Health ManagementCE
American Academy of Ambulatory Care Nursing (AAACN)
Population health management goes beyond traditional disease management and incorporates both preventive, wellness, and chronic care needs. The goal of population health management is to keep a patient population as healthy as possible. The RN in the CCTM Role uses population health management to organize systems of care for populations and to identify and implement evidence-based interventions and measure outcomes for both the individual and the population. Patient data including utilization data, medical record data, and evidence-based measures are used to stratify the population and aid the RN in identifying patients for outreach. Interventions include closing gaps in evidence-based measures and surrounding the patient with support to be successful in self-managing their health. A discussion of evolving health care policy development and its impact on regulatory and payer expectations and the provision of care to define populations will be discussed, as will the knowledge, skills, and attitudes necessary for the RN in the CCTM role. Purpose Statement: The purpose of this activity is to enable the learner to integrate the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role. 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: Population Health Management