CCTM ToolkitThe CCTM toolkit was developed as an online interactive toolkit that AAACN members can use to enhance and advance practice and increase the effectiveness of the role of the RN in CCTM.

It offers useful tools that support necessary materials to design, implement, or improve a CCTM program; including structure, process and outcome tools. CCTM resources are easy to find and easy to use!


To access the CCTM Toolkit, you must be logged in as a member of AAACN.

If you are a current member, simply log in for access.

If you aren't a member, please join AAACN now to enjoy access to this toolkit and so many other benefits of membership.


This toolkit from the American Academy of Ambulatory Care Nursing (AAACN) is designed to assist nurses and leaders working in the ambulatory care setting to develop and/or improve care coordination and transition management for patients.

Contained within are all the necessary materials to design, implement, or improve a CCTM program; including structure, process, and outcome tools.

Examples of some of these tools include: job descriptionsorientation programspolicies and procedures, and best practice outcome metrics.

To maintain the ongoing relevance and value of this toolkit, we welcome your suggestions.

CCTM Toolkit Resources

Within the structure of the toolkit, tools are grouped into the following major categories:


Refers to the conditions under which CCTM care is provided and includes the input elements and resources required to provide the care. Includes the providers of care, the tools and resources, and the physical and organizational setting in which they work; incorporates the human, physical, and financial resources needed to provide CCTM care.

Examples: CCTM RN job descriptions including qualifications and responsibilities, orientation program, reporting structure.


Refers to the content, actions, and procedures initiated by the CCTM RN and health care team in completing or facilitating the CCTM work; describes how the work is to be done.

Examples: Policies, procedures, standards for CCTM RN in performing the role, processes for communication between team members.


Refers to the desired states derived from the applied structure and processes; defines the desired result and how to measure.

Examples: Identified outcomes and targets, measures/metrics, outcomes tracking, reporting and communication, data sources.

To access the resources within the toolkit, you may choose below to either: Search the Toolkit by specific words or phrases; or, Browse the Toolkit by dimension of care to see the definition of that dimension and all the relevant toolkit resources, grouped by type and topic/source.