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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
After completing this learning activity, the learner will be able to identify and apply the concepts important to self-management and the primary components of self-management support. |
Objectives:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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:
Requirements for Successful Completion:
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.