Care Coordination and Transition Management


Standard: $245.00
Members: $195.00

Products

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

Preview Available

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


NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

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 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:
The purpose of this chapter is to enable the reader to understand the impact of a mutually developed, implemented, and continuously evaluated transition of care plan has on quality of care, patient satisfaction, patient outcomes, and financial impact, and understand the importance of integrating evidence-based practice guidelines into a transition of care plan.

Contact hours available until 12/31/2021.

Learning Outcome:
After completing this learning activity, the learner will be able to implement an evidence based format for transition of care between acute and ambulatory care with the outcome of quality care.


Objectives:

  1. Identify opportunities for transition management within the continuum of care.
  2. Identify key elements of successful transition planning.
  3. Review the most common factors influencing poor transition of care.
  4. Describe components of an evidence-based transition plan.
  5. List examples of transition of care models.
  6. Apply evidence-based format to coordinate information transfer between sites of care.
  7. Demonstrate the knowledge, skills, and attitudes required for transitions in care.

Requirements for Successful Completion:

  1. Read the PDF handout which is the chapter of the CCTM Core Curriculum that corresponds with this module.
  2. Listen to the module in its entirety.
  3. Complete the online CNE evaluation.


Faculty, Planners and Authors Conflict of Interest Disclosure:
Speaker(s) have no disclosures to declare.


Commercial Support and Sponsorship:
No commercial support or sponsorship declared.

Accreditation Statement:
This educational activity has been co-provided by Anthony J. Jannetti, Inc. and AAACN.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AAACN is a provider approved by the California Board of Registered Nursing, provider number CEP 5366.

Speaker(s):
Standard: $50.00
Members: $40.00

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

Preview Available

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


NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Informatics nursing practice is a technology that supports all dimensions of Care Coordination Transition Management (CCTM). The use of health information technology (HIT) is essential for safe care of patients in all health care settings and streamlines processes of coordinating care as patients transfer between different locations or levels of care. A discussion of the importance of using nationally recognized standardized terminologies across settings will be presented as will the integration of the knowledge, skills and attitudes between the RN-CCTM Model and informatics nursing practice.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the elements of competency in informatics nursing practice that are required for the registered nurse (RN) in Care Coordination and Transition Management (CCTM) role. Specific learning outcomes and objectives have been identified for each competency.

Recommended Reading:

Colorafi, K. (2016). Connected health: a review of the literature. 
    Mhealth, 2, 13. doi:10.21037/mhealth.2016.03.09

Linke, S. E., Larsen, B. A., Marquez, B., Mendoza-Vasconez, A., &
    Marcus, B. H. (2016). Adapting Technological Interventions to Meet
    the Needs of Priority Populations. Progress in Cardiovascular
    Diseases, 58
(6), 630-638.
    doi:https://doi.org/10.1016/j.pcad.2016.03.001

Milani, R. V., Bober, R. M., & Lavie, C. J. (2016). The Role of
    Technology in Chronic Disease Care. Progress in Cardiovascular
    Diseases, 58
(6), 579-583.
    doi:https://doi.org/10.1016/j.pcad.2016.01.001

Contact hours available until 12/31/2021.

Learning Outcome:

After completing this learning activity, the learner will be able to outline the elements of informatics nursing practice that define competence for the RN Care Coordination and Transition Management (CCTM) role.


Objectives:

  1. Explain why valid, reliable, and structured data/information is essential for safe and effective CCTM
  2. Identify essential information that must be available in a database to support coordination of care across providers and geographical settings.
  3. Describe the data, information, and knowledge required for use within health information technology to support care coordination and transition management.
  4. Describe the role of standardized terminologies in supporting communication of information between disparate electronic systems across providers and geographical settings.
  5. Show how the RN-CCTM Model can be used to identify the requirements for HIT to support care coordination and transition management.
  6. Evaluate requirements for the electronic care plan that support the RN-CCTM Model to support self-care management, cross-setting communication, and identification of high-risk and population management.


Requirements for Successful Completion:

  1. Read the PDF handout which is the chapter of the CCTM Core Curriculum that corresponds with this module.
  2. Listen to the module in its entirety.
  3. Complete the online CNE evaluation.


Faculty, Planners and Authors Conflict of Interest Disclosure:
Speaker(s) have no disclosures to declare.


Commercial Support and Sponsorship:
No commercial support or sponsorship declared.


Accreditation Statement:
This educational activity has been co-provided by Anthony J. Jannetti, Inc. and AAACN.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AAACN is a provider approved by the California Board of Registered Nursing, provider number CEP 5366.

Speaker(s):
Standard: $50.00
Members: $40.00

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

Preview Available

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


NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.


Telehealth nursing practice is an essential component of each of the dimensions for the RN in the CCTM role. The non-face-to-face setting adds yet another level of skills necessary to ensure practice that is safe, timely, and effective while coordinating care and managing transitions. In this module, a discussion of the knowledge, skills, and attitudes necessary to support the RN in the CCTM role will be presented as it applies to patients, caregivers and families using telecommunications technology. Specific emphasis will be placed on standards directing telehealth nursing, telehealth principles and practice, effective communication using telehealth technology, teamwork and collaboration, and technical know-how.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the elements of competency in professional telehealth nursing practice that are required for the RN in CCTM role.

Contact hours available until 12/31/2021.

Learning Outcome:
After completing this learning activity, the learner will be able to outline the elements of competency in professional telehealth nursing practice that are required for the RN Care Coordination and Transition Management (RN-CCTM) role.


Objectives:

  1. Relate telehealth practice standards to CCTM.
  2. Describe telehealth principles and practice as they relate to CCTM.
  3. Demonstrate principles of effective communication using telehealth technology in CCTM.
  4. Discuss the principles of teamwork and collaboration using telehealth technologies in CCTM.
  5. Discuss elements of technical know-how necessary to effectively perform CCTM using telecommunications technologies.

Requirements for Successful Completion:

  1. Read the PDF handout which is the chapter of the CCTM Core Curriculum that corresponds with this module.
  2. Listen to the module in its entirety.
  3. Complete the online CNE evaluation.


Faculty, Planners and Authors Conflict of Interest Disclosure:
Speaker(s) have no disclosures to declare.


Commercial Support and Sponsorship:
No commercial support or sponsorship declared.


Accreditation Statement:
This educational activity has been co-provided by Anthony J. Jannetti, Inc. and AAACN.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AAACN is a provider approved by the California Board of Registered Nursing, provider number CEP 5366.

Speaker(s):
Members: $40.00
Standard: $50.00
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