This section contains elements of competency in informatics nursing practice required of the CCTM RN. These competencies include: (1) Use of health information technology that is aligned with the RN-CCTM Model; (2) Explain why information and technology skills are essential for safe patient care; (3) Integration of national quality strategy requirements with use of HIT to improve care coordination and transition management.
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.
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.
A sample tool for assessing the care coordination process for pediatric patients in a hospital environment.
As part of it's Annual Conference educational programs, AAACN offers a CCTM Track designed to cover all aspects of CCTM practice.
In 2007 IHI launched initiatives to translate the Triple Aim concept into specific actions for change. The result was a model and a set of design concepts to fulfill the Triple Aim in practice.