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

Continuing Education Instructions and Disclosure Information:

Contact hours available until 7/1/2024.

Requirements for Successful Completion:
Complete the learning activity in its entirety and complete the online CNE evaluation. You will be able to print your CNE certificate at any time after you complete the evaluation.

Faculty, Planners, and Authors Conflict of Interest Disclosure:
There are no disclosures to declare.

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

Accreditation Statement:
This educational activity is jointly provided by Anthony J. Jannetti, Inc. (AJJ) 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.

Learning Outcome:
After completing this learning activity, the learner will be able to understand the outcomes of a mutually developed, implemented, and continuously evaluated transition of care plan and the impact it has on quality of care, individual and family satisfaction, and person-centered outcomes. In addition, recognizing the financial impact and understanding the importance of integrating evidence-based practice guidelines into a transition of care plan are essential components of care coordination and transition management (CCTM) and the role of the registered nurse (RN).

Learning Engagement Activity:
The CCTM nurse must identify key elements of successful transition planning, including identification of vulnerable populations. Read Case Study 11-1 and identify what risk-specific interventions were employed by the CCTM nurse.