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.

Framework for Measuring Nurses’ Contributions to Care Coordination

This report is the third in a series of ANA policy documents addressing care coordination and it presents the Framework by explaining its origin, detailing its component parts, and illustrating how it combines to inform quality measurement and improve care within the broader health care environment. The report’s supplements are intended to provide additional information and a summary of the supporting evidence base.

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.

Transitions of Care in the Long-Term Continuum

This clinical practice guideline (CPG) has been developed under a project conducted by the American Medical Directors Association (AMDA), and is intended for the members of the interdisciplinary team in long-term care facilities, including the medical director, director of nursing, practitioners, nursing staff, consultant pharmacist, and other professionals such as therapists, social workers, dietitians, and nursing assistants who care for residents of long-term care facilities.

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.