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

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

Self management support is essential in providing successful interventions to improve physical and personal outcomes for patients, their caregivers and families. This support is needed to increase their skills and confidence in managing their health problems, including their progress, goal setting and problem-solving. We must emphasize and support their self-reliance in dealing with their roles and the emotional management of their conditions. The RN in the CCTM role recognizes and supports the essential function patients, caregivers and families have in ensuring the health and well-being of the patient and in integrating all roles. The knowledge, skills and attitudes related to this dimension will be discussed in order to identify how the RN in CCTM can provide support for self-management.

Purpose:
The purpose of this learning activity is to enable the learner to demonstrate the primary components of self-management support, including the importance of a comprehensive needs assessment, common strategies for collaborative goal setting, and concepts important to self-management.

Recommended Reading:

Westland, H., Schroder, C. D., de Wit, J., Frings, J., Trappenburg, J.
    C. A., & Schuurmans, M. J. (2018). Self-management support in
    routine primary care by nurses. British Journal of Health
    Psychology, 23(1), 88-107. doi:10.1111/bjhp.12276

Contact hours available until 7/1/2024.

Learning Outcome:

Objectives:

1. Describe the concepts associated with support of self-management by ambulatory care registered nurses who are providing care coordination and transition management within the CCTM model.
2. Discuss the need for patient-centered assessment, and incorporation of patient values, goals, and preferences into planned care activities and approaches.
3. Outline the importance of recognizing the patient and health care team as equal partners in managing chronic conditions, with the RN in CCTM focused on building the patient’s and family’s knowledge, skills, and attitudes for self-management.
4. Identify patient self-management skills, gaps or barriers often encountered by members of the health care team.
5. Demonstrate understanding of knowledge, skills and attitudes that nurses need to support self-management in patients and families.

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.