Module 9: Care Coordination and Transition Management: Cross Setting Communications and Care Transitions

The need for communication across healthcare settings is critical in improving patient care. Data shows that ineffective communication can lead to negative events and unnecessary risks for patients. Patient acuity, co-morbidities, decreasing lengths of stay and increasing financial pressures all contribute to the need for complete and timely transitions of care. This module will review methods and processes of ensuring complete transitions of care, as well as challenges related to inadequate communication. Tools used by the RN in the CCTM role, which help to facilitate successful care transitions will be introduced and discussed.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the knowledge, skills, and attitudes required for Cross-Setting Communication and Transitions in Care.

Contact hours available until 3/31/2020.

Learning Outcome:
After completing this learning activity, the learner will be able to demonstrate the knowledge, skills, and attitudes required for Cross-Setting Communication and Transitions in Care.

Objectives:
1. Explain the concept of care transitions.
2. Explain the communication deficiencies that commonly occur with care transitions.
3. Define the role of the ambulatory care RN in CCTM in cross-setting communication and care transition.
4. Identify key characteristics of effective communication for care transitions.
5. Design and implement processes to provide sufficient, timely, and useful information necessary to achieve the successful patient care transitions.
6. Analyze processes and identify improvement opportunities in cross-setting communication.
7. Evaluate evidence and do small tests of change to improve cross-setting communication during care transitions.
8. Demonstrate the knowledge, skills, and attitudes required for Cross-Setting Communication and Transitions in Care.

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.