Care Coordination and Transition Management Core Curriculum

The Care Coordination and Transition Management (CCTM) Core Curriculum text covers nine evidence-based dimensions: 1. Advocacy 2. Education and engagement of patients and families 3. Coaching and counseling of patients and families 4. Patient-centered care planning 5. Support for self-management 6. Nursing process (proxy for monitoring and evaluation) 7. Teamwork and collaboration 8. Cross setting communications and care transitions 9. Population health management There is also an introduction chapter, a 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. There are two chapters 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.

Sheila A. Haas, PhD, RN, FAAN, is Professor, Marcella Niehoff School of Nursing, Loyola University Chicago, Maywood, IL, and Past President, American Academy of Ambulatory Care Nursing Beth Ann Swan, PhD, CRNP, FAAN, is Dean and Professor, Thomas Jefferson University, Philadelphia, PA,and Past President, American Academy of Ambulatory Care Nursing Traci S. Haynes, MSN, RN, CEN, is Director of Clinical Services, LVM Systems, Mesa, AZ, and Past President, American Academy of Ambulatory Care Nursing