Care Coordination and Transition Management

This course includes contact hours.

The CCTM online course and core text will help nurses solve the puzzle of fragmented patient care. It is an evidence-based, patient centered program designed to:

• Improve patient outcomes
• Enhance access to quality care
• Decrease hospital readmissions
• Decrease health care costs
• Help patients navigate the health care system
• Ensure continuity and seamless transitions among levels and settings of care
• Work effectively in Patient-Centered Medical Homes (PCMHs)and Accountable Care Organizations (ACOs)
• Improve the individual patient’s experience of care

Please Note: ANCC has determined it will not refresh the CCCTM exam. The credential will continue to be available for renewal only to nurses who already hold the credential. ANCC is exploring board certification(s) that align with population health needs for the future, and AAACN has been invited to explore in collaboration with ANCC.

For more information regarding CCCTM, visit the ANCC Website.

Please contact ANCC at certification@ana.org for more information about how to renew your certification through ANCC.

Contact hours available until 7/1/2024.

Original CCTM content was reviewed and updated in December 2018. Content was found relevant, and additional newer references have been added.

The course includes an audio presentation, slides, and a PDF version of the corresponding core text chapter. Nurses will read the chapter prior to viewing the audio presentation. The course provides 26.4 contact hours.

If you've already purchased this course, be sure to log in to access it from this page directly.

Module 1: Care Coordination and Transition Management: Introduction

Preview Available

Module 1: Care Coordination and Transition Management: Introduction

Identification: CCTM01

Credits: None available.

• Dr. Sheila A. Haas, PhD, RN, FAAN, Marcella Niehoff School of Nursing at Loyola University
• Traci Haynes, MSN, RN, CEN, CCCTM
• Kathy Mertens, DNP, MPH, RN, Associate Chief Nurse for Ambulatory Care and Population Health, University of Washington Medicine
• Mary Sue Dailey, MSN, APN-CNS, Clinical Nurse Specialist/Adult Acute Medical- Surgical, Advocate Good Samaritan Hospital
• Jamie Bland, MSN, RN
• Barbara Trehearne, PhD, RN

Module 2: Care Coordination and Transition Management: Advocacy

Preview Available

Module 2: Care Coordination and Transition Management: Advocacy

Identification: CCTM02

Credits: None available.

• Vicki Grant, MS, RN
• Author Mary H. Vinson, DNP, RN-BC
• Judith Toth-Lewis, RN, BSN, MSN, PhD

Module 3: Care Coordination and Transition Management: Education and Engagement of Patients and Families

Preview Available

Module 3: Care Coordination and Transition Management: Education and Engagement of Patients and Families

Identification: CCTM03

Credits: None available.

• Author Cheryl A. Lovlien, MS, RN-BC

Module 4: Care Coordination and Transition Management: Coaching and Counseling of Patients and Families

Preview Available

Module 4: Care Coordination and Transition Management: Coaching and Counseling of Patients and Families

Identification: CCTM04

Credits: None available.

• Judy Dawson-Jones, BSN, RN, MPH
• Kristene K. Grayem, MSN, CNS, PPCNP-BC, RN-BC, Chief Population Health Officer, Akron Children's Hospital
• Karen Alexander, PhD, RN

Module 5: Care Coordination and Transition Management: Patient-Centered Care Planning

Preview Available

Module 5: Care Coordination and Transition Management: Patient-Centered Care Planning

Identification: CCTM05

Credits: None available.

• Anne T. Jessie, DNP, RN, Senior Director for Population Health Management and Clinical Innovations, Gorman Health
• Kathleen T. Sheehan, MS, BSN, RN-BC, CH-GCN
• Judith Toth-Lewis, RN, BSN, MSN, PhD

Module 6: Care Coordination and Transition Management: Support for Self-Management

Preview Available

Module 6: Care Coordination and Transition Management: Support for Self-Management

Identification: CCTM06

Credits: None available.

• Author Candia B. Laughlin, MS, RN-BC
• Stephanie G. Witwer, PhD, RN, NEA-BC, FAAN, Nurse Administrator, Mayo Clinic

Module 7: Care Coordination and Transition Management: Nursing Process: Proxy for Monitoring and Evaluation

Preview Available

Module 7: Care Coordination and Transition Management: Nursing Process: Proxy for Monitoring and Evaluation

Identification: CCTM07

Credits: None available.

• Traci Haynes, MSN, RN, CEN, CCCTM

Module 8: Care Coordination and Transition Management: Teamwork and Collaboration

Preview Available

Module 8: Care Coordination and Transition Management: Teamwork and Collaboration

Identification: CCTM08

Credits: None available.

• Mary A. Bord-Hoffman, MA, MN, RN-BC, Nurse Manager
• Denise Hannagan, MSN, MHA, RN-BC, EDAC, Senior Healthcare Consultant, HDR, Inc.
• Kathy Mertens, DNP, MPH, RN, Associate Chief Nurse for Ambulatory Care and Population Health, University of Washington Medicine

Module 9: Care Coordination and Transition Management: Cross Setting Communications and Care Transitions

Preview Available

Module 9: Care Coordination and Transition Management: Cross Setting Communications and Care Transitions

Identification: CCTM09

Credits: None available.

• Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC
• Janet Fuchs, MBA, MSN, RN, NEA-BC, Cleveland Clinic
• Deborah Aylard, MSN, RN

Module 10: Care Coordination and Transition Management: Population Health Management

Preview Available

Module 10: Care Coordination and Transition Management: Population Health Management

Identification: CCTM10

Credits: None available.

• Anne T. Jessie, DNP, RN, Senior Director for Population Health Management and Clinical Innovations, Gorman Health
• Barbara Trehearne, PhD, RN
• Sheila Johnson, RN, MBA