Module 11: Care Coordination and Transition Management: Between Acute Care and Ambulatory Care

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 3/31/2020.

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 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.