This section will assist in identifying primary components of self-management in the CCTM role, including assisting patients with identifying barriers in self-management. The CCTM RN will provide comprehensive care recognizing the patient as the source of control in his or her care process. This section contains Structure, Process, and Outcomes in providing support for the self-management of the patient.
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.
This guide was commissioned by the Agency for Healthcare Research and Quality (AHRQ) to identify ways evidence-based strategies for reducing readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.
The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.
The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks to screen for signs of clinical depression.
An assessment tool to measure caregiver strain in individuals caring for chronically-disabled patients.
An abbreviated cognitive assessment tool for healthcare providers.
A mobility assessment tool for healthcare providers.
The GAD-7 tool is used to assess the state of patients with generalized anxiety disorder.
A functional assessment tool used for care planning with the geriatric patient.
A screening tool for drug and alcohol use.