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

Patient and family centered care is essential in designing a plan of care. A pre-visit chart review and visit planning will be discussed as will the need for performing a comprehensive needs assessment of the patient to appropriately develop a plan for interventions founded in evidence-based guidelines. The RN in the CCTM role recognizes the integral part patients, families and caregiver have in ensuring the health and well-being of patients; and is aware that by engaging patients and their family in care plan development improved patient outcomes, increased patient and family satisfaction, restoration of dignity and control, and better management of resource allocation results. The ability to identify gaps in care, utilize motivational interviewing and the importance of the multidisciplinary collaboration across the continuum of care.

Purpose Statement:
The purpose of this chapter is to enable the reader to demonstrate the ability to develop, implement, and provide ongoing management of a comprehensive plan of care – based upon the individual patient’s values, preferences, and needs – in partnership with the primary care provider and larger interdisciplinary care team.

Contact hours available until 3/31/2020.

Learning Outcome:
After completing this learning activity, the learner will be able to develop, implement, and manage a comprehensive plan of care in partnership with the primary care provider and larger interdisciplinary care team.

Objectives:
1. Perform a comprehensive needs assessment on the patient focusing on the overall needs so interventions can be planned and accurately implemented.
2. Identify gaps in care and individualize the plan focus through a pre-visit chart review and visit planning.
3. Describe the process for identification of high-risk populations and determine appropriate risk.
4. Utilize motivational interviewing as a communication style to guide the patient and family planning to make positive behavior changes to improve health.
5. Develop a plan of care utilizing input from patient, family, and multidisciplinary team members.
6. Design interventions founded in evidence- based clinical guidelines.
7. Demonstrate the knowledge, skills, and attitudes required for patient-centered care planning.

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 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.