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CCTM01 - Module 1: Care Coordination and Transition Management: Introduction

‐ Jul 11, 2022 12:00pm

Credits: None available.

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.

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.


  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.




Credits Available

Module 1: Care Coordination and Transition Management: Introduction

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Diana Dragon
5/26/17 5:02 am

Thank you

Irene Benally-Holmes
7/21/17 4:27 pm

Good example of care coordination of patients given

11/8/17 9:54 am

I enjoyed the thorough overview and content of this course

Flora Ramos
11/9/17 4:24 pm

I just viewed this module, and I want to say that I listened to the whole program without having reviewed the handout and it has inspired me to continue learning from you guys! So now I will read my handout and listen to this again. Thank you for putting this together.

Kimberly LaFleur
2/1/18 2:59 pm

Module 1 provides a very thorough introduction to the CCTM course. I am extremely impressed with the level of expertise, collaboration and research that have gone into developing this course. The presenters are clearly knowledgeable and passionate about the RN CCTM role, and I look forward to the completing the course.

Elizabeth Satrom
2/27/18 5:21 pm

Excellent! Thank you for all of the hard work in creating this valuable resource.

Michelle Reagan
3/24/18 11:16 am

Content inspired continued learning

Leigh Waters
9/19/18 9:25 am

Great introduction to the program!

Lisa Casady
9/23/18 1:13 pm

This was an excellent introduction to CCCTM and I am so excited to learn more and put in my daily work practice.

patricia goodman
11/21/18 9:43 am

Very good session.

Geri Holden
2/18/19 3:59 pm

Thank you.

Ninette Tan
3/5/19 7:54 pm

It is great to see how all the components of healthcare are being integrated into one model! I agree with the speakers that new graduate BSN students should have this as part of their curriculum. I learned a lot about valuable patient care coordination from working for a specialty pharmacy doing the education for discharged patients that I never would have known working in the hospital. Looking forward to the next modules, thank you.

James Martinez-Ruiz
3/27/19 8:10 pm

Excellent presentation.

Jacqueline Hargis
6/5/19 5:30 pm

Supports RN practice care RN achieve higher lever of care policy data collection with core curriculum prepares nurse to lead. Tracking patient care. expands mind set.

Katherine Poling
6/16/19 4:33 pm

excellent opening to the core curriculum work/focus

Shehnaz Nayani
7/24/19 10:07 am

Thank you, enjoyed learning and reviewing evidenced based dimensions.

Anna Curtis
8/21/19 6:43 pm

Absolutely fantastic content provided by impressive presenters. Looking forward to this course!

Priscilla Young
10/22/19 5:28 pm

Looking forward to the upcoming modules; thanks for a great introduction to this course.

Andrea Savoren
11/29/19 7:45 pm

Very interesting. I currently am working with these patients. Thank you

Janis Hess
4/22/21 9:47 pm

The overview of the course was great

Feng Ping Lee
12/4/23 4:14 pm

Thank you