This fact sheet provides background on payable CCM service codes,identi es eligible practitioners and patients, and details the Medicare PFS billing requirements.

The Transtheoretical Model is an integrative, biopsychosocial model to conceptualize the process of intentional behavior change. Whereas other models of behavior change focus exclusively on certain dimensions of change (e.g. theories focusing mainly on social or biological influences), the TTM seeks to include and integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings.

Through the collaboration between the Medical-Surgical Nursing Certification Board (MSNCB) and the American Academy of Ambulatory Care Nursing (AAACN), a variety of study resources have been developed. Nurses will find these resources helpful when preparing for the CCCTM exam. They vary on material, learning styles, and cost (including Free!).

The CCTM online courses cover nine dimensions of the RN’s CCTM role and related competencies for care coordination and transition management.

This position paper reflects the current state of ambulatory care and the crucial role of the RN as a care provider, care coordinator, and care partner. It also highlights potential role changes and adaptations for the future.