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• W2555033698 abstract "Volume 35, No. 3 • January/February 2014 The United States health care system is challenged in its efforts to effectively manage people with complex health care needs from an access, quality, and cost perspective (Agency for Healthcare Research and Quality [AHRQ], 2012; Grundy, Hagan, Hansen, & Grumbach, 2010). To enhance access to quality and cost effective care, the Affordable Care Act (ACA) promotes the use of Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). In addition, for more than a decade, national reports have called for patient-centric care models as one strategy to improve quality care (Institute of Medicine [IOM], 2001). A 2011 IOM report, The Future of Nursing, again called for care that is patientcentric and identified the need to reconsider the roles of health professionals – including RNs – and transform practices related to care coordination and transition management. Coordinating care and managing transitions across multiple providers and settings requires patient-centered interprofessional collaborative (IPC) practice teams, and RNs are ideally positioned to serve in the care coordinator/transition manager role (American Nurses Association [ANA], 2012). Recognizing the potential of the RN to contribute to enhanced quality, cost effectiveness, and access to care in ambulatory settings, the Board of Directors of the American Academy of Ambulatory Care Nursing (AAACN) created a care coordination and transition management (CCTM) competencies action plan with three phases to delineate RN competencies and develop an education program for care coordination and transition management in ambulatory care. The deliverable for Action Phase I was to create a table of evidence; Action Phase II was to develop core competencies for care coordination and transition management dimensions; and Action Phase III was to review the care coordination and transition management dimensions and competencies within each and design a care coordination and transition management role for RNs working with ambulatory care patients with complex chronic illnesses. This work resulted in a core curriculum text to support the development of RNs in ambulatory care settings to fulfill the role of coordinating care and managing transitions. In addition, structured education for each dimension and online education modules are in production. This groundbreaking text, Care Coordination and Transition Management Core Curriculum, contains 13 chapters. The majority of the book is composed of the nine chapters listed below, one for each evidence-based dimension, written by nurse experts. This compilation is the work of a large number of ambulatory care and acute care nurse leaders representing practice, education, and re search. 1. Advocacy 2. Education and engagement of pa tients and families 3. Coaching and counseling of pa tients and families 4. Patient-centered care planning 5. Support for self-management Care Coordination and Transition Management Competencies for Practicing and Student Nurses" @default.
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• W2555033698 title "Care Coordination and Transition Management Competencies for Practicing and Student Nurses" @default.
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