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.
A nursing course presented by Johns Hopkins Univeristy that focuses on the use of a guided care model to address the lack of an efficient, cost-effective way to respond to the needs of patients with either chronic illnesses or co-morbidities.
An overview of the GRACE Team Care model for in-home assessment and care management of common geriatric conditions by a team of experts.
The Care Transitions Intervention® is also known as the CTI®, the Skill Transfer Model™, the Coleman Transitions Intervention Model® and the Coleman Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home.
This article reviews assessment of patient learning styles in combination with context for an individualized approach, as well as motivation for adult learners as a framework for organization of patient teaching. Methods and modes of patient teaching are discussed as well as tips for overcoming barriers to planning and implementing patient teaching.
The law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable; including expanding the Medicaid program to cover more people with low incomes.
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance.
Guided Care® helps primary care practices meet the complex needs of patients with multiple chronic conditions. In this proven care model, a trained Guided Care nurse works closely with patients, physicians and others to provide coordinated, patient-centered care.
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.