AAACN Care Coordination and Transition Management Core Curriculum for RN Practice Across Settings, 2nd Edition
The Care Coordination and Transition Management (CCTM) Core Curriculum text covers nine evidence-based dimensions:
- Advocacy
- Education and engagement of patients and families
- Coaching and counseling of patients and families
- Patient-centered care planning
- Support for self-management
- Nursing process (proxy for monitoring and evaluation)
- Teamwork and collaboration
- Cross setting communications and care transitions
- Population health management
There is also an introduction chapter 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. Two chapters are devoted to technologies that provide decision support and information systems for all dimensions of care coordination and transition management: one focused on informatics, and one focused on telehealth nursing practice.
The text is written for nurses in all settings; from ambulatory care to hospitals, extended care facilities to student nurses. The text is evidence-based and is organized to include definitions, learning outcomes and objectives, a table of knowledge, skills, and attitudes (KSAs), and nationally-recognized core competencies for quality and safety education for nurses (QSEN), inter-professional collaborative practice, and public health nursing competencies.
Articles
Chapter 1: Introduction
Credits: None available.
Author(s):
- Beth A. Swan, PhD, CRNP, FAAN, Jefferson School of Nursing Thomas Jefferson University
Author(s):
- Dr. Sheila A. Haas, PhD, RN, FAAN, Marcella Niehoff School of Nursing at Loyola University
- Traci Haynes, MSN, RN, CEN, CCCTM
- Cynthia L. Murray, BN, AMB-BC, Clinical Nurse Advisor for Primary Care, Veterans Health Administration
Chapter 2: Advocacy
Credits: None available.
Author(s):
- Author Mary H. Vinson, DNP, RN-BC
- William Duffy, RN, MJ, CNOR, FAAN
Chapter 3: Education and Engagement of Individuals, Families/Caregivers
Credits: None available.
Author(s):
- Author Cheryl A. Lovlien, MS, RN-BC
- Denise Rismeyer, MSN, RN-BC
- Jayme Speight, MSN, RN-BC
Chapter 4: Coaching and Counseling of Individuals and Families
Credits: None available.
Author(s):
- Karen Alexander, PhD, RN
- Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
- Judy Dawson-Jones, BSN, RN, MPH
- Mary C. Houlihan, MS, RN, CCRN
Chapter 5: Person-Centered Care Planning
Credits: None available.
Author(s):
- Carol A. Newman, DNP, MSED, MSS, MSN, RN, CPNP-PC
- Dawn M. Gerz, RN, MSN, MBA, NEA-BC, RN-BC
- Judith Toth-West, RN, BSN, MSN, PhD
- Jayme Speight, MSN, RN-BC
Chapter 6: Support for Self-Management
Credits: None available.
Author(s):
- Author Vanessa M. DeBiase, MSN, Med, RN, NPD-BC
- Author Kathryn D. Swartwout, PhD, APRN, FNP-BC
- Pa Xiong, MSN, RN, CCCTM
Chapter 7: Nursing Process
Credits: None available.
Author(s):
- Susan Paschke, MSN, RN, AMB-BC, NEA-BC, Part-Time Faculty, Kent State University
Author(s):
- Author Jude Sell-Gutowski, MSN, BSN, RN-BC
- Kristine Meagher, MSN, RN, ACNS-BC, CCCTM
Chapter 8: Teamwork and Collaboration
Credits: None available.
Author(s):
- Maribeth Kelly, MSN, RN, PCCN, CCCTM
- Frances R. Vlasses, PhD, RN, NEA-BC, ANEF, FAAN
- Lisa Wus, DNP, RN, FNP-BC, PCCN-CMC, CCCTM
Chapter 9: Cross-Setting Communications and Care Transitions
Credits: None available.
Author(s):
- Tina Truong, MS, RN, CCCTM
- Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC
- Jayme Speight, MSN, RN-BC
- Cynthia R. Niesen, DNP, MA, RN, NEA-BC
Chapter 10: Population Health Management
Credits: None available.
Author(s):
- Author Eileen M. Esposito, DNP, RN, AMB-BC, CPHQ
- Sheila Johnson, RN, MBA
- Barbara Trehearne, PhD, RN
- Jayme Speight, MSN, RN-BC
- Anne T. Jessie, DNP, RN, Senior Director for Population Health Management and Clinical Innovations, Gorman Health