Development of a model for the registered nurse in care coordination and transition management provides nurses the opportunity to develop the knowledge, skills, and attitudes to be a resource to the team and to patients, and to contribute to high-quality patient and organization outcomes.

The American Organization of Nurse Executives and the American Academy of Ambulatory Care Nursing collaborated to outline how nurse leaders in inpatient and post-acute/outpatient settings should approach their roles to enhance development of care coordination and transition management across the continuum of care.

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.

Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduatequality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency.

NANDA International (NANDA-I), the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) are comprehensive, research-based, standardized classifications of nursing diagnoses, nursing interventions and nursing-sensitive patient outcomes. These classifications provide a set of terms to describe nursing judgments, treatments and nursing-sensitive patient outcomes.

Diagnostic information and nursing care plans for several common health issues.

This fact sheet provides background on payable CCM service codes,identi es eligible practitioners and patients, and details the Medicare PFS billing requirements.

Through the collaboration between the Medical-Surgical Nursing Certification Board (MSNCB) and the American Academy of Ambulatory Care Nursing (AAACN), a variety of study resources have been developed. Nurses will find these resources helpful when preparing for the CCCTM exam. They vary on material, learning styles, and cost (including Free!).

The CCTM online courses cover nine dimensions of the RN’s CCTM role and related competencies for care coordination and transition management.

This position paper reflects the current state of ambulatory care and the crucial role of the RN as a care provider, care coordinator, and care partner. It also highlights potential role changes and adaptations for the future.