Teamwork and collaboration are essential in the CCTM RN role. Teamwork is a structure ensuring each member is aware of each other's roles and competencies, while collaboration ensures there is open communication and shared decision-making amongst each of the members of the team. This section contains structure, process, and outcomes in team development, team roles, communication, impact of team and safety and quality care, and impact of team on systems.

View the Logic Model

ANA Position Statement on Care Coordination and the Essential Role of the Registered Nurse

Care coordination is a necessary foundation to achieving the “triple aim” of health reform – improved patient experience of care (quality, access and reliability), improved population health, and per capita cost control. This position statement articulates the essential role of the registered nurse in the care coordination process.

Developing the Value Proposition for the Role of the Registered Nurse in Care Coordination and Transition Management in Ambulatory Care Settings

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.

Joint Statement: The Role of the Nurse Leader in Care Coordination and Transition Management across the Health Care Continuum

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.

The Value of Nursing Care Coordination - ANA White Paper

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.

Patient Aligned Care Teams (PACT) Model

PACT is the cornerstone of the New Models of Care initiative that is intended to transform the way Veterans receive care. PACT assists VHA in transforming Veterans' care by providing patient-driven, proactive, personalized, team-based care focused on wellness and disease prevention resulting in improvements in Veteran satisfaction, improved healthcare outcomes, and costs. The PACT model is built on the well-known concept of the patient-centered medical home staffed by high-functioning teams.

Subscribe to Teamwork and Collaboration