Process | American Academy of Ambulatory Care Nursing

AAACN Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management

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This publication includes the definition of CCTM, defining characteristics for RNs practicing in the CCTM role, and an initial conceptual framework that was adapted from models cited in the Care Coordination and Transition Management Core Curriculum. The framework offers a structure for cataloguing and unifying the distinct relationships and interactions among the professional nurse, the patient, group and/or population, the inter-professional health care team, and the resources across the health care continuum.

Introduction to Dementia Care Mapping™

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Dementia Care MappingTM is designed to empower staff teams to engage in evidence-based critical reflection in order to improve the quality of care for people living with dementia. It provides a direct and ongoing evidence base for practice and practice change. As such, it provides an excellent example of the principles of care mapping, in general; for any condition.

Team Strategies & Tools to Enhance Performance and Patient Safety - Communication

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Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based framework to optimize team performance across the health care delivery system. The communication tools within this framework are excellent guidelines for hand-off communications during care transition.

Interventions to Reduce Acute Care Transfers (INTERACT®)

Read more about Interventions to Reduce Acute Care Transfers (INTERACT®)

INTERACT® is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.

The Hospital Guide to Reducing Medicaid Readmissions

Read more about The Hospital Guide to Reducing Medicaid Readmissions

This guide was commissioned by the Agency for Healthcare Research and Quality (AHRQ) to identify ways evidence-based strategies for reducing readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.