Care Coordination and Transition Management Scope and Standards

How do you describe the RN in CCTM role?
Looking for practice standards for the RN in CCTM?

The Care Coordination and Transition Management Scope and Standards from the American Academy of Ambulatory Care Nursing (AAACN) describes the role and the standards of practice for the RN practicing CCTM in a variety of settings such as:

  • Ambulatory or outpatient care
  • Acute care or hospitals
  • Post-acute care
  • Schools
  • Diverse community settings

Use this resource as a tool to:

  • Advance professional CCTM practice and population health.
  • Prepare for the CCCTM (Certified in Care Coordination and Transition Management) exam.
  • Develop competencies, standards, policies, and procedures.
  • Create role descriptions and performance appraisal instruments.
  • Develop performance improvement initiatives for CCTM practice.
  • Stimulate CCTM research and evidence-based practice.
  • Guide ethical practice and patient advocacy in CCTM.

The CCTM Scope and Standards includes:

  • Definitions of CCTM
  • Defining characteristics for RNs practicing in the CCTM role
  • Initial conceptual framework for CCTM practice
  • 16 standards addressing the clinical and management competencies of CCTM practice

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The following standards are pertinent to the ambulatory care setting:


Ambulatory Care Nursing

These standards promote effective clinical and administrative management of increasingly complex ambulatory care RN roles and responsibilities in a changing health care environment.

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Telehealth Nursing

Telehealth is an integral part of ambulatory care nursing practice. These standards promote effective clinical and administrative management of services provided by RNs via telecommunications technology.

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Care Coordination and Transition Management (CCTM)

CCTM is a critical role for RNs in the transformation of health care. These standards describe the responsibilities for which RNs practicing CCTM are accountable in ambulatory care and other settings.

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