Care Transitions Program
Under the direction of Eric A. Coleman, MD, MPH, the Care Transitions Program® will help you manage risk and empower patients during care hand-overs.
Coaching and counseling of patients encompasses communication and teamwork. The CCTM RN guides and directs patients to improve their care. This section contains 5 A's Behavior Change Model, Patient-Provider Interaction, Standard Operating Procedures, and Community and Organizational Policies.
Under the direction of Eric A. Coleman, MD, MPH, the Care Transitions Program® will help you manage risk and empower patients during care hand-overs.
AAACN has developed a number of resources focused on CCTM; including the CCTM Model, CCTM Core Curriculum, and CCTM online modules.
As recent studies suggest, professional nurses have the potential for significant contributions to patient-centered, cost-effective care through the care coordination role. In order to fully achieve this potential, clear models and outcome measures are needed which specify the context for care coordination, identify nursing competencies, and value the nurse’s role within the health care team.
This clinical practice guideline (CPG) has been developed under a project conducted by the American Medical Directors Association (AMDA), and is intended for the members of the interdisciplinary team in long-term care facilities, including the medical director, director of nursing, practitioners, nursing staff, consultant pharmacist, and other professionals such as therapists, social workers, dietitians, and nursing assistants who care for residents of long-term care facilities.
The Ottawa Personal Decision Guide is for people who are facing tough decisions, such as those with critical health issues. It will help you instruct the patient on how to identify personal needs, plan next steps, track progress, and communicate views to others involved when making health care decisions.
The 5 A’s Behavior Change Model is intended for use with the Improving Chronic Illness Care Chronic Care Model (CCM), and was created with the goal of ensuring that all patients have a Self-Management (SM) Action Plan informed by and including all the 5 A’s elements (Assess, Advise, Agree, Assist, Arrange).
A resource that defines teach-back and provides guidelines for the successful use of that approach when assessing a patient's understanding of their condition and care.
As part of it's Annual Conference educational programs, AAACN offers a CCTM Track designed to cover all aspects of CCTM practice.
In 2007 IHI launched initiatives to translate the Triple Aim concept into specific actions for change. The result was a model and a set of design concepts to fulfill the Triple Aim in practice.
A sample checklist for patients about to be discharged to ensure that they have a full understanding of their condition and what they need to do as a result.