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


The Course is also a useful resource to help you prepare for the Certified in Care Coordination and Transition Management (CCCTM) exam provided by the Medical-Surgical Nursing Certification Board (MSNCB) in collaboration with AAACN. 

Contact hours available until 12/31/2021.

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.

Standard: $245.00
Members: $195.00

Packages Display Packages

Care Coordination and Transition Management
Includes 13 Sessions
Click here for details, pricing and to purchase

Sessions Included:

Module 1: Care Coordination and Transition Management: Introduction ()

Module 2: Care Coordination and Transition Management: Advocacy ()

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

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

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

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

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

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

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

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

Module 11: Care Coordination and Transition Management: Between Acute Care and Ambulatory Care ()

Module 12: Care Coordination and Transition Management: Informatics Nursing Practice ()

Module 13: Care Coordination and Transition Management: Telehealth Nursing Practice ()

Standard: $245.00
Members: $195.00

Sessions

Module 1: Care Coordination and Transition Management: Introduction Module 1: Care Coordination and Transition Management: Introduction

Preview Available

Module 1: Care Coordination and Transition Management: Introduction


Identification: CCTM01

Credits: None available.

Speaker(s):
Tags: logic model care coordination competency cctm interprofessional transition management improved outcomes dimensions
Standard: Free
Module 2: Care Coordination and Transition Management: AdvocacyModule 2: Care Coordination and Transition Management: Advocacy

Preview Available

Module 2: Care Coordination and Transition Management: Advocacy


Identification: CCTM02

Credits: None available.

Speaker(s):
Tags: care coordination competency cctm collaboration transition management autonomy beneficence advocacy health teaching and promotion ethics
Standard: $50.00
Members: $40.00
Module 3: Care Coordination and Transition Management: Education and Engagement of Patients and FamiliesModule 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.

Speaker(s):
Tags: care coordination competency cctm education transition management engagement of patients and families readiness to learn assessing knowledge collaboration and teamwork method of teaching
Standard: $50.00
Members: $40.00
Module 4: Care Coordination and Transition Management: Coaching and Counseling of Patients and FamiliesModule 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.

Speaker(s):
Tags: care coordination competency cctm transition management coaching counseling relationship empower patients care team communication 5 a's behavior change model
Members: $40.00
Standard: $50.00
Module 5: Care Coordination and Transition Management: Patient-Centered Care PlanningModule 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.

Speaker(s):
Tags: cctm assessment care coordination competency transition management patient-centered care planning motivational interviewing plan of care interventions risk identification
Standard: $50.00
Members: $40.00
Module 6: Care Coordination and Transition Management: Support for Self-ManagementModule 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.

Speaker(s):
Tags: self-management care coordination competency cctm transition management chronic conditions cognitive assessment self care barriers to self-management
Standard: $50.00
Members: $40.00
Module 7: Care Coordination and Transition Management: Nursing Process: Proxy for Monitoring and EvaluationModule 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.

Speaker(s):
Tags: care coordination competency nursing process cctm transition management monitoring evaluation critical thinking outcomes orlando's theory
Members: $40.00
Standard: $50.00
Module 8: Care Coordination and Transition Management: Teamwork and CollaborationModule 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.

Speaker(s):
Tags: care coordination competency standards cctm collaboration teamwork transition management professional practice team-based health care team leader
Standard: $50.00
Members: $40.00
Module 9: Care Coordination and Transition Management: Cross Setting Communications and Care TransitionsModule 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.

Speaker(s):
Tags: communication care coordination competency cctm transition management care transitions fudge model guided care grace
Standard: $50.00
Members: $40.00
Module 10: Care Coordination and Transition Management: Population Health ManagementModule 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.

Speaker(s):
Tags: care coordination competency population health cctm transition management stratification interdisciplinary care team chronic care model patient engagement population identification
Members: $40.00
Standard: $50.00
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