Care Coordination and Transition Management

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 7/1/2024.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Patient advocacy is the support and empowerment of patients to make informed decisions, navigate the healthcare system to access appropriate care and build strong partnerships with providers, while working towards system improvement to support patient-centered care. Transformation of the U.S. healthcare system will require that nurses recognize and commit to patient advocacy as an important element of care coordination and transition management.

Professional nursing standards and competencies which support the RN-CCTM advocacy role are examined, along with a look at nursing's responsibilities at the system level to assure policies which optimize the care coordination and transition management needs of patients and families in the emerging healthcare environment.

Purpose:
The purpose of this activity is to enable the learner to integrate professional standards of nursing related to advocacy into the RN Care Coordination and Transition Management (RN-CCTM) role.

Recommended Reading:

Grace, P., & Milliken, A. (2016). Educating Nurses for Ethical Practice       
     in Contemporary Health Care Environments. Hastings Center
     Report, 46 Suppl 1, S13-17. doi:10.1002/hast.625 

Milliken, A. (2017). Toward Everyday Ethics: Strategies for Shifting
     Perspectives. AACN Advanced Critical Care, 28(3), 291-296.
     doi:10.4037/aacnacc2017406

Milliken, A., & Grace, P. (2017). Nurse ethical awareness:
     Understanding the nature of everyday practice.Nursing Ethics,
     24(5), 517-524. doi:10.1177/0969733015615172

O'Connor, M. (2018). Advocacy: Perspectives of Future Nurse
     Administrators. Nursing Administration Quarterly, 42(2), 136-142.
     doi:10.1097/naq.0000000000000283

Persaud, S. (2018). Addressing Social Determinants of Health Through
     Advocacy. Nursing Administration Quarterly, 42(2), 123-128.
     doi:10.1097/naq.0000000000000277

Contact hours available until 7/1/2022.

After completing this learning activity, the learner will be able to integrate professional standards of nursing related to advocacy into the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Apply the ethical principles of autonomy, beneficence, fidelity, and justice to the RN-CCTM role of patient advocate.
2. Identify provisions in the Patient Protection and Affordable Care Act (PPACA) which require that health care providers advocate for patient needs, goals and preferences.
3. Demonstrate patient advocacy in all RN-CCTM activities.
4. Recognize the importance of RN-CCTM participation in organizational and public policy formation that facilitates advocacy for patients in ambulatory care.
5. Describe the application of professional practice standards to the RN-CCTM role in ambulatory care.
6. Discuss the concept of patient advocacy as it relates to ethical principles.
7. Develop and implement a plan of care in collaboration with the patient that reflects advocacy needs, interventions and outcomes.
8. Describe ways in which ambulatory care nurses can influence policy development focused on advocacy on behalf of patients, families and nursing in ambulatory care.
9. Demonstrate the knowledge, skills and attitudes required for the Advocacy dimension.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Patient education is a process of assisting individuals to learn about their health care and influence behaviors to increase health and independence. Education of families is important in supporting the patient with the expectation that patients and families will adapt and apply health practices to improve health care outcomes. To achieve this goal, patients and families need to understand health, illness, and influencing factors through communication that meets their level of understanding in a manner that is respectful and engaging.

A review of education principles and theories of learning which support the RN in the CCTM role will be discussed; as will methods to assess patient and family learning needs that promote an open learning environment in which they can work toward self management and optimal health.

Purpose:
The purpose of this chapter is to enable the reader to identify methods to assess patient and family learning needs, create learning opportunities, and promote an open learning environment in which the learner works toward self-management and optimal health.

Recommended Reading:

Hawley, S. T., & Morris, A. M. (2017). Cultural challenges to engaging
    patients in shared decision making. Patient Education and
    Counseling, 100(1), 18-24.

Hibbard, J. (2017). Patient Activation and Health Literacy: What's the
    Difference? How Do Each Contribute to Health Outcomes. Studies
    in Health Technology and Informatics, 240, 251-262. 

Hibbard, J. H. (2017). Patient activation and the use of information to
    support informed health decisions. Patient Education and
    Counseling, 100(1), 5-7.

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to identify methods to assess patient and family learning needs and promote an open learning environment in which the learner works toward self-management and optimal health.

Objectives:

1. Identify patient and family education needs, goals, and expected behavioral outcomes.
2. Discuss steps to assess learning needs, readiness to learn, health literacy needed to plan, implement, and evaluate education and learning across the lifespan for patients and family members.
3. Employ methods to engage patients/families and caregivers in health care.
4. Review educational principles and theories of learning.
5. Apply methods of teaching and learning that focus on special populations and how they best learn, assimilate information, and improve outcomes.
6. Employ methods such as "teach back" to assess learning and health literacy.
7. Demonstrate the knowledge, skills, and attitudes required for patient education and engagement in learning.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Coaching and counseling of patients and their families is an important dimension of the RN in the CCTM role in order to develop a trusting relationship and provide health information and guidance in setting goals and accessing resources. Acknowledging and utilizing the strengths of patients’ existing support structure is vital. Strategies will be discussed to assist the RN in the CCTM role in empowering patients and families. The RN in CCTM works with patients and families to understand and cope with their illness and navigate the healthcare system to access appropriate care, build strong partnerships with providers, and influence their outcomes.

Purpose:
The purpose of this chapter is to enable the reader to utilize the existing strengths of the care team to create innovative ways to engage patients and families in the care plan.

Recommended Reading:

Huffman, M. H. (2016). Advancing the Practice of Health Coaching: 
    Differentiation From Wellness Coaching. Workplace Health & 
    Safety, 64(9), 400-403. doi:10.1177/2165079916645351

Ostlund, A. S., Wadensten, B., Haggstrom, E., Lindqvist, H., & 
    Kristofferzon, M. L. (2016). Primary care nurses' communication 
    and its influence on patient talk during motivational interviewing. 
    Journal of Advanced Nursing, 72(11), 2844-2856. 
    doi:10.1111/jan.13052

Wallace, A. M., Bogard, M. T., & Zbikowski, S. M. (2018). Intrapersonal 
    Variation in Goal Setting and Achievement in Health Coaching: 
    Cross-Sectional Retrospective Analysis. Journal of Medical Internet 
    Research, 20(1), e32. doi:10.2196/jmir.8892

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to identify innovative approaches to engage patients and families and make them an active partner in the plan of care.

Objectives:

1. Discuss methods of developing a relationship with the patients and families in order to capitalize on their strengths and identify the barriers to fulfilling care plan goals.
2. Demonstrate respect and valuing of patients and families preferences, interaction styles, and goals.
3. Describe strategies to empower patients and families in all aspects of the health care process (Cronenwett et al., 2007)
4. Explain how to equip patients and families with the tools needed to fulfill their responsibilities.
5. Discuss ways to maintain a relationship with patients and families in order to guide and reinforce the care plan.
6. Demonstrate competence by positive patient outcomes as evidenced by increased care team communication, decreased emergency department visits, and hospital re-admissions.
7. Demonstrate the knowledge, skills, and attitudes required for the Coaching and Counseling of Patients and Families dimension.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Patient and family centered care is essential in designing a plan of care. A pre-visit chart review and visit planning will be discussed as will the need for performing a comprehensive needs assessment of the patient to appropriately develop a plan for interventions founded in evidence-based guidelines. The RN in the CCTM role recognizes the integral part patients, families and caregiver have in ensuring the health and well-being of patients; and is aware that by engaging patients and their family in care plan development improved patient outcomes, increased patient and family satisfaction, restoration of dignity and control, and better management of resource allocation results. The ability to identify gaps in care, utilize motivational interviewing and the importance of the multidisciplinary collaboration across the continuum of care.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the ability to develop, implement, and provide ongoing management of a comprehensive plan of care – based upon the individual patient’s values, preferences, and needs – in partnership with the primary care provider and larger interdisciplinary care team.

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to develop, implement, and manage a comprehensive plan of care in partnership with the primary care provider and larger interdisciplinary care team.

Objectives:

1. Perform a comprehensive needs assessment on the patient focusing on the overall needs so interventions can be planned and accurately implemented.
2. Identify gaps in care and individualize the plan focus through a pre-visit chart review and visit planning.
3. Describe the process for identification of high-risk populations and determine appropriate risk.
4. Utilize motivational interviewing as a communication style to guide the patient and family planning to make positive behavior changes to improve health.
5. Develop a plan of care utilizing input from patient, family, and multidisciplinary team members.
6. Design interventions founded in evidence- based clinical guidelines.
7. Demonstrate the knowledge, skills, and attitudes required for patient-centered care planning.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Self management support is essential in providing successful interventions to improve physical and personal outcomes for patients, their caregivers and families. This support is needed to increase their skills and confidence in managing their health problems, including their progress, goal setting and problem-solving. We must emphasize and support their self-reliance in dealing with their roles and the emotional management of their conditions. The RN in the CCTM role recognizes and supports the essential function patients, caregivers and families have in ensuring the health and well-being of the patient and in integrating all roles. The knowledge, skills and attitudes related to this dimension will be discussed in order to identify how the RN in CCTM can provide support for self-management.

Purpose:
The purpose of this learning activity is to enable the learner to demonstrate the primary components of self-management support, including the importance of a comprehensive needs assessment, common strategies for collaborative goal setting, and concepts important to self-management.

Recommended Reading:

Westland, H., Schroder, C. D., de Wit, J., Frings, J., Trappenburg, J.
    C. A., & Schuurmans, M. J. (2018). Self-management support in
    routine primary care by nurses. British Journal of Health
    Psychology, 23(1), 88-107. doi:10.1111/bjhp.12276

Contact hours available until 7/1/2024.

Learning Outcome:

Objectives:

1. Describe the concepts associated with support of self-management by ambulatory care registered nurses who are providing care coordination and transition management within the CCTM model.
2. Discuss the need for patient-centered assessment, and incorporation of patient values, goals, and preferences into planned care activities and approaches.
3. Outline the importance of recognizing the patient and health care team as equal partners in managing chronic conditions, with the RN in CCTM focused on building the patient’s and family’s knowledge, skills, and attitudes for self-management.
4. Identify patient self-management skills, gaps or barriers often encountered by members of the health care team.
5. Demonstrate understanding of knowledge, skills and attitudes that nurses need to support self-management in patients and families.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

We all know Nursing Process. It is the essential core of our practice and has been engrained in us from our basic training forward. And we know patient and family-centered care is essential in designing a plan of care that will achieve optimal outcomes. We will review nursing process, but more importantly in this presentation is how the RN in the CCTM role will enhance nursing process. Health coaching to facilitate behavior change over time, self-management, autonomy, informed decision making, accessing resources and adherence to the medical regimen will also be discussed. Critical thinking is applied in every step; and the knowledge, skills, and attitudes will be identified with emphasis on the CCTM role.

Purpose:
The purpose of this chapter is to enable the reader to use the required steps in the nursing process when performing in the role of the RN in CCTM.

Recommended Reading:

Sanson, G., Vellone, E., Kangasniemi, M., Alvaro, R., & D'Agostino, F.
    (2017). Impact of nursing diagnoses on patient and organisational
    outcomes: a systematic literature review. Journal of Clinical
    Nursing, 26(23-24), 3764-3783. doi:10.1111/jocn.13717

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to demonstrate application of the steps in the nursing process when performing in the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Outline the steps of the nursing process and how the steps promote critical thinking.
2. Identify the skills necessary for application of the nursing process in ambulatory care.
3. Apply the nursing process in ambulatory care.
4. Explain how to determine if outcomes are achieved.
5. Explain adaptations and additions to the steps in the nursing process required when performing as an RN in CCTM.
6. Demonstrate the knowledge, skills, and attitudes required for the Nursing Process dimension.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Teamwork and collaboration are dynamic processes involving healthcare professionals sharing common healthcare goals and working toward a common end in assessing, planning, implementing or evaluating patient care. A focus on type of care and how that care is delivered to patients and their caregivers and family is of utmost importance, and must be delivered by strong inter-professional teams to be effective. The Institute of Medicine has emphasized the key role nurses play not just as members of inter-professional teams, but also as leaders within the team. Discussed will be the knowledge, skills, and attitudes necessary for the nurse in the RN-CCTM role and the team-based best practices for innovative collaboration that result in positive patient care processes and outcomes.

Purpose:
The purpose of this activity is to enable the learner to apply effective teamwork and collaboration skills into the RN Care Coordination and Transition Management (RN-CCTM) role.

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to apply effective teamwork and collaboration skills into the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Define teamwork and collaboration.
2. Identify the importance of teamwork and collaboration and the effect on patient care processes and outcomes.
3. Describe evidence-based strategies that support teamwork including overcoming common barriers.
4. Describe the role of the RN-CCTM within a team.
5. Demonstrate how the RN-CCTM practices the knowledge, skills and attitudes required for Teamwork and Collaboration.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

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 7/1/2024.

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Population health management goes beyond traditional disease management and incorporates both preventive, wellness, and chronic care needs. The goal of population health management is to keep a patient population as healthy as possible. The RN in the CCTM Role uses population health management to organize systems of care for populations; and to identify and implement evidence-based interventions and measure outcomes for both the individual and the population. Patient data including utilization data, medical record data, and evidence based measures are used to stratify the population and aid the RN in identifying patients for outreach. Interventions include closing gaps in evidence based measures and surrounding the patient with support to be successful in self-managing their health. A discussion of evolving health care policy development and its impact on regulatory and payer expectations and the provision of care to define populations will be discussed as will the knowledge, skills, and attitudes necessary for the RN in the CCTM role.

Purpose:
The purpose of this activity is to enable the learner to integrate the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role.

Recommended Reading:

Linke, S. E., Larsen, B. A., Marquez, B., Mendoza-Vasconez, A., &
    Marcus, B. H. (2016). Adapting Technological Interventions to Meet
    the Needs of Priority Populations. Progress in Cardiovascular
    Diseases, 58(6), 630-638.
    doi:https://doi.org/10.1016/j.pcad.2016.03.001

Sheff, A., Park, E. R., Neagle, M., & Oreskovic, N. M. (2017). The
    patient perspective: utilizing focus groups to inform care
    coordination for high-risk medicaid populations. BMC Research
    Notes, 10(1), 315. doi:10.1186/s13104-017-2638-1

Contact hours available until 7/1/2024.

Learning Outcome:
After completing this learning activity, the learner will be able to integrate the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Explain the purpose of population health management (PHM) and how it applies to the registered nurse (RN) in the Care Coordination and Transition Management (CCTM) role in ambulatory care.
2. Define and describe key elements of PHM.
3. Apply key elements of PHM to RN in CCTM practice.
4. Describe the benefits of having data for managing a population.
5. Discuss methods organizations employ for storage and management of data.
6. Describe the value of stratification of risk within a population.
7. Identify the value of closing gaps in care.
8. Identify key members of the interdisciplinary care team and discuss how they contribute to discipline-based interventions that are a part of population management.
9. Discuss methods to engage and activate patients and their caregivers in partnering in care management.
10. Define and identify wraparound services that are essential for ongoing care and support for populations.
11. Discuss how informatics and decision-support tools are utilized in the provision of population health management.
12. Describe elements for measuring population management from an individual and group perspective.
13. Interpret evolving health care policy development and appropriately comply with quality monitoring, and regulatory and payer expectations in the provision of care to defined populations.
14. Demonstrate the knowledge, skills, and attitudes required for PHM (see Tables 1 and 2).

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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Transitioning patients from one care setting to another and coordinating their care ensures health care continuity while avoiding preventable poor outcomes. While the process sounds simplistic, the reality is as patients move from one level of care to another, among multiple providers and across settings the process can derail and communication can break down. An engaged health care team working collaboratively with the patient, family, and caregivers can improve quality of care, patient satisfaction, and patient outcomes. The importance of integrating evidence-based practice guidelines into transitions of care along with the knowledge, skills, and attitudes of the RN in the CCTM role will be discussed. A patient scenario is used to illustrate how tools for transitioning from one level of care to another can be applied.

Purpose:
The purpose of this chapter is to enable the reader to understand the impact of a mutually developed, implemented, and continuously evaluated transition of care plan has on quality of care, patient satisfaction, patient outcomes, and financial impact, and understand the importance of integrating evidence-based practice guidelines into a transition of care plan.

Contact hours available until 7/1/2024.

Learning Outcome:
After completing this learning activity, the learner will be able to implement an evidence based format for transition of care between acute and ambulatory care with the outcome of quality care.

Objectives:

1. Identify opportunities for transition management within the continuum of care.
2. Identify key elements of successful transition planning.
3. Review the most common factors influencing poor transition of care.
4. Describe components of an evidence-based transition plan.
5. List examples of transition of care models.
6. Apply evidence-based format to coordinate information transfer between sites of care.
7. Demonstrate the knowledge, skills, and attitudes required for 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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Informatics nursing practice is a technology that supports all dimensions of Care Coordination Transition Management (CCTM). The use of health information technology (HIT) is essential for safe care of patients in all health care settings and streamlines processes of coordinating care as patients transfer between different locations or levels of care. A discussion of the importance of using nationally recognized standardized terminologies across settings will be presented as will the integration of the knowledge, skills and attitudes between the RN-CCTM Model and informatics nursing practice.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the elements of competency in informatics nursing practice that are required for the registered nurse (RN) in Care Coordination and Transition Management (CCTM) role. Specific learning outcomes and objectives have been identified for each competency.

Recommended Reading:

Colorafi, K. (2016). Connected health: a review of the literature. 
    Mhealth, 2, 13. doi:10.21037/mhealth.2016.03.09

Linke, S. E., Larsen, B. A., Marquez, B., Mendoza-Vasconez, A., &
    Marcus, B. H. (2016). Adapting Technological Interventions to Meet
    the Needs of Priority Populations. Progress in Cardiovascular
    Diseases, 58(6), 630-638.
    doi:https://doi.org/10.1016/j.pcad.2016.03.001

Milani, R. V., Bober, R. M., & Lavie, C. J. (2016). The Role of
    Technology in Chronic Disease Care. Progress in Cardiovascular
    Diseases, 58(6), 579-583.
    doi:https://doi.org/10.1016/j.pcad.2016.01.001

Contact hours available until 7/1/2024.

Learning Outcome:

After completing this learning activity, the learner will be able to outline the elements of informatics nursing practice that define competence for the RN Care Coordination and Transition Management (CCTM) role.

Objectives:

1. Explain why valid, reliable, and structured data/information is essential for safe and effective CCTM
2. Identify essential information that must be available in a database to support coordination of care across providers and geographical settings.
3. Describe the data, information, and knowledge required for use within health information technology to support care coordination and transition management.
4. Describe the role of standardized terminologies in supporting communication of information between disparate electronic systems across providers and geographical settings.
5. Show how the RN-CCTM Model can be used to identify the requirements for HIT to support care coordination and transition management.
6. Evaluate requirements for the electronic care plan that support the RN-CCTM Model to support self-care management, cross-setting communication, and identification of high-risk and population 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 to 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.

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Telehealth nursing practice is an essential component of each of the dimensions for the RN in the CCTM role. The non-face-to-face setting adds yet another level of skills necessary to ensure practice that is safe, timely, and effective while coordinating care and managing transitions. In this module, a discussion of the knowledge, skills, and attitudes necessary to support the RN in the CCTM role will be presented as it applies to patients, caregivers and families using telecommunications technology. Specific emphasis will be placed on standards directing telehealth nursing, telehealth principles and practice, effective communication using telehealth technology, teamwork and collaboration, and technical know-how.

Purpose:
The purpose of this chapter is to enable the reader to demonstrate the elements of competency in professional telehealth nursing practice that are required for the RN in CCTM role.

Contact hours available until 7/1/2024.

Learning Outcome:
After completing this learning activity, the learner will be able to outline the elements of competency in professional telehealth nursing practice that are required for the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Relate telehealth practice standards to CCTM.
2. Describe telehealth principles and practice as they relate to CCTM.
3. Demonstrate principles of effective communication using telehealth technology in CCTM.
4. Discuss the principles of teamwork and collaboration using telehealth technologies in CCTM.
5. Discuss elements of technical know-how necessary to effectively perform CCTM using telecommunications technologies.

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 to 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.