This section contains structure, process, and outcomes in communication, team building and collaboration, quality improvement using evidence-based practice, and informatics to ensure effective care transition communication is performed by the CCTM RN.
The core concept of the reconceptualized model of certified practice - the AACN Synergy Model for Patient Care - is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit or system are matched with a nurse's competencies.
This resource is a modified version of the LACE tool, focused on nursing; and incorporating additional checklists for more comprehensive discharge planning and assessment.
The LACE tool is one of meany designed to assess risk of patient readmission or death upon discharge.
The 8P Screening Tool is designed to identify a patient's risk for adverse events after discharge.
The National Database of Nursing Quality Indicators® (NDNQI®) delivers evidence to support the importance of nurse sensitive measures in overall patient experience strategy.
The CALNOC registry captures and benchmarks unit data, structural measures, process measures, and outcome measures.
Dementia Care MappingTM is designed to empower staff teams to engage in evidence-based critical reflection in order to improve the quality of care for people living with dementia. It provides a direct and ongoing evidence base for practice and practice change. As such, it provides an excellent example of the principles of care mapping, in general; for any condition.
Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based framework to optimize team performance across the health care delivery system. The communication tools within this framework are excellent guidelines for hand-off communications during care transition.
INTERACT® is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.
An assessment tool to measure caregiver strain in individuals caring for chronically-disabled patients.