The CCTM RN is vital in improving the care coordination of the patient between acute care and ambulatory care. This section contains structure, process, and outcomes in identifying key elements of successful transition planning, exemplars of transition care models in patient-centered care, safety, teamwork and collaboration, and evidence-based practice.

Code of Ethics for Nurses

The Code of Ethics for Nurses with Interpretive Statements (The Code) was developed by the American Nurses Association as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.

Guided Care®

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.