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CCTM04 - Module 4: Care Coordination and Transition Management: Coaching and Counseling of Patients and Families

‐ Jun 29, 2022 12:00pm

Credits: None available.

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.

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. 

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.


  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.




Credits Available

Module 4: Care Coordination and Transition Management: Coaching and Counseling of Patients and Families

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Lori Hestand
8/31/23 1:06 pm

Good instruction on this module from all parties