Module 1: Care Coordination and Transition Management: Introduction

The need for care coordination and management of transitions between Patient-Centered Medical Home providers, outpatient and community settings, including the Accountable Care Organization is often overlooked, episodic, and accountability for coordinating care and managing transitions between providers and services is lacking. AAACN recognized the potential of the RN to contribute to enhanced quality, cost effectiveness and access to care in ambulatory settings; and supported the creation of an evidence-based CCTM Core Curriculum and On-line Education Modules developed by experts representing practice, education, and research across the United States.

This module discusses the RN-CCTM Model, defines care coordination and transition management, identifies the nine dimensions of CCTM and the technologies that provide decision support and information systems for all dimensions; and describes the competencies necessary to support the role of the RN-CCTM.

There will be 12 education modules to follow as part of the CCTM Course. Nine will cover the evidence-based dimensions, two will cover the technologies (i.e., Informatics Nursing Practice and Telehealth Nursing Practice), and one 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.

Purpose: The purpose of this activity is to enable the learner to identify key components of the CCTM Core Curriculum.

Contact hours available until 3/31/2017.

Learning Outcome:
After completing this learning activity, the learner will be able to define care coordination and transition management and list the RN Care Coordination and Transition Management (RN-CCTM) competencies.

Objectives:
1. Discuss the RN-CCTM model.
2. Define care coordination and transition management.
3. Identify the dimensions of care coordination and transition management.
4. Describe competencies for care coordination and transition management.

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 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.