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CCTM12 - Module 12: Care Coordination and Transition Management: Informatics Nursing Practice

Credits: None available.

Informatics nursing practice is a technology that supports all dimensions of Care Coordination Transition Management (CCTM). The use of health information technology (HIT) is essential for safe care of patients in all health care settings and streamlines processes of coordinating care as patients transfer between different locations or levels of care. A discussion of the importance of using nationally recognized standardized terminologies across settings will be presented as will the integration of the knowledge, skills and attitudes between the RN-CCTM Model and informatics nursing practice.

The purpose of this chapter is to enable the reader to demonstrate the elements of competency in informatics nursing practice that are required for the registered nurse (RN) in Care Coordination and Transition Management (CCTM) role. Specific learning outcomes and objectives have been identified for each competency.

Contact hours available until 3/31/2020.

Learning Outcome:
After completing this learning activity, the learner will be able to outline the elements of informatics nursing practice that define competence for the RN Care Coordination and Transition Management (CCTM) role.


  1. Explain why valid, reliable, and structured data/information is essential for safe and effective CCTM
  2. Identify essential information that must be available in a database to support coordination of care across providers and geographical settings.
  3. Describe the data, information, and knowledge required for use within health information technology to support care coordination and transition management.
  4. Describe the role of standardized terminologies in supporting communication of information between disparate electronic systems across providers and geographical settings.
  5. Show how the RN-CCTM Model can be used to identify the requirements for HIT to support care coordination and transition management.
  6. Evaluate requirements for the electronic care plan that support the RN-CCTM Model to support self-care management, cross-setting communication, and identification of high-risk and population 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 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.



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Credits: None available.

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