Care Coordination Transition Management

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 outlines the development of an innovative residency program to increase expanded nursing roles by providing structured training using an established ambulatory care curriculum, expert mentorship, and co-design with practice administration…

This session discusses the development of a care coordination pilot program to address complex needs of pediatric gastroenterology patients, with the goals of preventing overuse of the emergency room and inpatient admissions while increasing compliance with plans of care…

This session addresses the effectiveness of shared medical appointments as a tool for educating patients on lifestyle changes that positively impact metabolic syndrome…

This session addresses the development of a full-time program to provide continuity and dedicated education for all patient-aligned care team (PACT) members in outpatient clinics…

CCTM is growing nationwide, and a set of principles and evidence-based resources are constantly being created and updated to support ambulatory care nursing. The CCTM SIG meets to discuss the latest evidence-based tools and research…

In these short rapid-fire presentations, multiple speakers highlight approaches to managing issues related to telehealth in the practice environment…

This session discusses the development of a chronic disease care management program at our academic medical center to address the needs of complex moderate- to high-risk patients and reduce repeat emergency department utilization and hospital readmissions for these specified populations…

Sudden cardiac death is the leading medical cause of death in young athletes. Sports physical exams are used to establish the safety of athletes’ sports participation. Pediatric mobile clinics have been found to increase access to care in communities that are underserved…

Patients transitioning from an inpatient hospital stay to self-care responsibilities post-discharge are at risk for readmission, resulting in increased cost and resource utilization. Care transition programs can result in cost avoidance and decreased resource utilization…

Purpose: The purpose of this presentation is to discuss the implementation and impact of nurse-led visits in ambulatory specialty care settings at an academic medical center…

This presentation discusses the implementation strategy for centralizing nursing services to support primary care practices as well as the tools and tactics for tracking RN work and value-based program outcomes as a result of centralization…

Ambulatory care is a rapidly growing field of nursing practice. As this specialty practice grows, there have been efforts to identify the desired role of the registered nurse in ambulatory care and link it to patient outcomes…

Having a warfarin protocol in place is only half the battle. It is imperative that protocol be followed and documented with each encounter. This presentation discusses how to closely monitor labs and provide care for the non-compliant patient…

Seeking the right level of care at the right time can help prevent delay in care and unnecessary cost. Different modes to seek care have been developed to meet the complex needs of patients, but patients may not be able to track the resources available to them…

In a value-based care environment, successful outcome measures include improved quality of care while limiting costs. This session discusses a transitional care program implemented to support post-discharge follow-up…

This presentation demonstrates the VA's national approach to cover PACT RN care manager vacancies, keeping the PACT unit intact by utilizing remote RNs to provide care to patients virtually…

This session discusses the interventions leading to the successful implementation of RN-led visits for chronic disease management in the primary care setting…

Purpose: The study purpose is to recruit and educate baccalaureate nursing students to practice to the full scope of their licensure in community-based primary care settings…

Purpose: The purpose of this project was to increase early identification of patients with cognitive impairment through use of the mini-cog screening tool…

Background: To ensure efficient and effective care for our rising and high-risk patients, ambulatory care services conducted an analysis of current case management (CM) and direct care registered nurse (RN) services…

Objectives: Identify the role of the emergency department clinical nurse leader (CNL), focus of practice in a community hospital, and key care coordination strategies used…

Introduction: Whether routine screening for depression among patients in primary care medicine improves identification and treatment of the disorder remains unclear…

This presentation outlines program results since 2019 of a 6-month intensive university led post-baccalaureate residency/fellowship designed to prepare practice ready RNs in primary care…