AAACN Care Coordination and Transition Management Core Curriculum for RN Practice Across Settings, 2nd Edition



The Care Coordination and Transition Management (CCTM) Core Curriculum text covers nine evidence-based dimensions:

  1. Advocacy
  2. Education and engagement of patients and families
  3. Coaching and counseling of patients and families
  4. Patient-centered care planning
  5. Support for self-management
  6. Nursing process (proxy for monitoring and evaluation)
  7. Teamwork and collaboration
  8. Cross setting communications and care transitions
  9. Population health management

There is also an introduction chapter dedicated to the transition from acute care to ambulatory care and the critical nature of hand-offs in ensuring patient safety and quality of care. Two chapters are devoted to technologies that provide decision support and information systems for all dimensions of care coordination and transition management: one focused on informatics, and one focused on telehealth nursing practice.

The text is written for nurses in all settings; from ambulatory care to hospitals, extended care facilities to student nurses. The text is evidence-based and is organized to include definitions, learning outcomes and objectives, a table of knowledge, skills, and attitudes (KSAs), and nationally-recognized core competencies for quality and safety education for nurses (QSEN), inter-professional collaborative practice, and public health nursing competencies.

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The Core is the background for AAACN's CCTM Course, which offers 26.4 contact hours. 

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Chapter 1: Introduction

Chapter 1: Introduction


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Chapter 2: Advocacy

Chapter 2: Advocacy


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Chapter 3: Education and Engagement of Individuals, Families/Caregivers

Chapter 3: Education and Engagement of Individuals, Families/Caregivers


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Chapter 4: Coaching and Counseling of Individuals and Families

Chapter 4: Coaching and Counseling of Individuals and Families


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Chapter 5: Person-Centered Care Planning

Chapter 5: Person-Centered Care Planning


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Chapter 6: Support for Self-Management

Chapter 6: Support for Self-Management


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Chapter 7: Nursing Process

Chapter 7: Nursing Process


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Chapter 8: Teamwork and Collaboration

Chapter 8: Teamwork and Collaboration


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Chapter 9: Cross-Setting Communications and Care Transitions

Chapter 9: Cross-Setting Communications and Care Transitions


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Chapter 10: Population Health Management

Chapter 10: Population Health Management


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