Aiming to improve the transition of patients from hospital to home, a team at one healthcare organization completed a performance improvement project leveraging the registered nurse to lead the transition of care phone call and visit in collaboration with the primary care physician. This session explores the results of the performance improvement project and address when the RN leads the TOC process to identify and address patient needs in a care management approach, the patient’s risk of readmission decreases.

Continuing Education Instructions and Disclosure Information:

Contact hours available until 4/6/2026.

Requirements for Successful Completion:
Complete the learning activity in its entirety and complete the online nursing continuing professional development (NCPD) evaluation. You will be able to print your NCPD certificate at any time after you complete the evaluation.

Disclosure of relevant financial relationships with ineligible companies (planners, faculty/speakers, reviewers):

Planning Committee Disclosures:
There are no Planning Committee disclosures to declare.

Speaker Disclosures:
There are no speaker disclosures to declare.

Commercial Support:
No commercial support declared.

Accreditation Statement:
This educational activity is jointly provided by Anthony J. Jannetti, Inc. (AJJ) and the American Academy of Ambulatory Care Nursing (AAACN).

Anthony J. Jannetti, Inc. is accredited as a provider of nursing continuing professional development 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 participant will be able to summarize the steps to establish registered nurse-led transition care management processes in practice.

Jennifer Wagner MSN RN NE-BC

Appearances