Table of Contents A Message from AAACN President . v Foreword . vi Preface . viii Contributors. ix Reviewers . xi Expert Panels . xiii Acknowledgments . xiv Chapter 1 . .of . 1 Introduction Chapter 2 . 13 Advocacy Chapter 3 . 23 Education and Engagement of Patients and Families Chapter 4 . 37 Coaching and Counseling of Patients and Families Nursing Chapter 5 . 47 Patient-Centered Care Planning Academy Chapter 6 . 65 Support for Self-Management Chapter 7 . .Care . 77 Nursing Process (Proxy for Monitoring and Evaluation) Chapter 8 . 89 Teamwork and Collaboration Chapter 9 . 101 Cross-Setting Communications and Care Transitions Chapter 10 . 113 Population HealthAmerican Management Chapter 11 . 141 Care Coordination© and Transition Management (CCTM) Between Acute Care and Ambulatory Care Chapter 12 . 163 Informatics Nursing Practice Chapter 13 . Ambulatory. 175 Telehealth Nursing Practice Glossary. 189 Resources . 199 AAACN Fact Sheet . 201 Index . 203 Copyright © 2014 – American Academy of Ambulatory Care Nursing (AAACN) iii A Message from AAACN President The wait is over! The Care Coordination and Transition Management (CCTM) Core Curriculum Is Here ealth care reform and the Patient Protection and Afford- For our three editors – Sheila A. Haas, PhD, RN, FAAN; Hable Care Act (2010) challenged the American health Beth Ann Swan, PhD, CRNP, FAAN; and Traci S. Haynes, care system to find ways to manage the complex health MSN, RN, BA, CEN – this project has been a labor of love! needs of the population by increasing access to care and They have worked tirelessly to facilitate the work of the Ex- managing costs while providing the highest quality of care. pert Panels and to champion the publication of this cutting- Interprofessional patient-centered care models like the Pa- edge text and educational courseof that will serve as a CCTM tient-Centered Medical Home and Accountable Care Or- resource for all registered nurses. The AAACN Board of Di- ganizations are designed to provide personalized care rectors and I thank our editors, the nurses and other pro- management with “RNs ideally positioned to serve in the fessional colleagues who served on the Expert Panels, and care coordinator/transition manager role” (Haas, Swan, & the authors and reviewers who worked so diligently to bring Haynes, 2013, p. 45). Safe, efficient, and effective transitions the vision of this Core Curriculum to reality. We also ac- between providers, levels of care, and various care settings knowledge the Academy of Medical-Surgical Nurses will be key factors to the success of these models. (AMSN) for their collaboration in serving on the Expert Pan- The vision for this much anticipated text grew out of the els; for their assistance in developing the chapter “Care Co- need and desire for evidence-based registered nurse (RN) ordination and TransitionNursing Management Between Acute Care competencies to provide education for and demonstrate the and Ambulatory Care;” and for their endorsement of the effectiveness of the role of the RN in care coordination and Core Curriculum. transition management (CCTM). The American Academy I hope that you find this outstanding publication to be a of Ambulatory Care Nursing (AAACN) developed an actionAcademyvaluable resource in your nursing practice wherever you co- plan in 2011 to initiate this endeavor. The project included ordinate care or manage patient transitions. three phases for the core curriculum development and a fourth phase to include the development of an online edu- CareSusan M. Paschke, MSN, RN-BC, NEA-BC cation course (Haas et al., 2013). AAACN President, 2013-2014 Four separate interprofessional Expert Panels were convened. The first reviewed and analyzed the literature. References The second defined the nine dimensions and the core com- Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory care petencies and associated activities related to RN care co- registered nurse competencies for care coordination and transition ordination and transition management. The third built upon management. Nursing Economic$, 31(1), 44-49, 43. the work of the first two panels and created the table of ev- Patient Protection and Affordable Care Act. (2010). Public Law 111-148, § 2702, 124 Stat. 119, 318-319. idence which includes the competencies and the knowl- edge, skills, and attitudes necessary to fulfill this important role. A fourth panel of nurse leaders and experts from am- bulatory and acuteAmerican care was enlisted to develop and create this Core Curriculum and the online course corresponding to the content© of the text. Ambulatory Copyright © 2014 – American Academy of Ambulatory Care Nursing (AAACN) v Foreword A Competency Model to Improve Quality and Safety, Care Coordination, and Transitions ealth care has been in continual change over the past leges of Nursing, 2012; Cronenwett et al., 2007). The goal Hfew decades, implementing multiple strategies to im- of QSEN (www.QSEN.org) is the integration of the six com- prove outcomes. Nurses are increasingly positioned to help petencies into all of nursing so that quality and safety are lead these changes through advancements in nursing ed- part of nurses’ daily work: patient-centered care, teamwork ucation and refocusing professional practice models. Com- and collaboration, evidence-based practice, quality im- petency models are one strategy for improving care by provement, safety, and informatics. These competencies describing standardized care objectives that address the are now part of nursing educationof standards and other reg- shortcomings identified in the Institute of Medicine report ulatory and certification guidelines. To Err is Human (IOM, 1999), and the quality goals de- The Care Coordination and Transition Management scribed in the Crossing the Quality Chasm report (IOM, Core Curriculum provides a critical step in improving quality 2001). These reports revealed startling gaps in health care and safety of care and helps nurses understand better how and proposed a quality framework, STEEEP, to improve to incorporate the QSEN competencies in practice. Patient- care outcomes: all care should be Safe, Timely, Equitable, centered care is at the heart of safety; the Care Coordina- Efficient, Effective, and Patient-centered. These goals, in tion and Transition Management standards describe addition to changes from the 2012 Affordable Care Act, are specific evidence-based principles for accurate and per- changing health care access, delivery, and reimbursement sonalized assessment as the basis for patient-centered dramatically. The 2010 IOM report Future of Nursing called care. Safety awarenessNursing is even more important in consid- for nurses to practice to their fullest preparation and also ering the unique practice settings that include advanced to seek advanced educational mobility to lead changes in practice nurses who may be in independent or group prac- improving care. Thus, nurses are uniquely positioned to tice, nurses who must communicate and share care goals provide key leadership in improving care managementAcademyamong interprofessional colleagues, and those who man- across the myriad care delivery settings, but need guide- age small care teams or supervise unlicensed personnel. lines for specific settings and populations that help meet Recognizing breakdowns in processes is the first step to new regulations and reimbursement demands. Caredevelop quality improvement initiatives that can close gaps between ideal and actual performance measures. Compe- A Competency-Based Resource tency in informatics provides a key strategy for communi- This Care Coordination and Transition Management cation, decision support, and documentation. Core Curriculum is a just-in-time competency-based re- source to guide nurses in the new delivery systems and Making Care Standards Accessible payment directives. Increasing complexity of care, diverse The potential power of this Core Curriculum is in mak- practice settings, and payer requirements are key factors ing care standards readily accessible to nurses. Standard- that position nurses to have a leading role in care manage- ization in care is a major component of safe care. ment across providers and transitions in care. The Core Evidence-based standards share best practices based on Curriculum addressesAmerican competencies for improving care the latest evidence gathered from the literature and docu- outcomes among the multiple dimensions of growing com- mented experiences. Nurses are the constant patient care plexity of care in diverse settings, and, in particular, ambu- providers who spend the most time with patients, and as latory ©populations. Most guidelines and evidence-based such, have key information for making care decisions. standards have been developed based on acute care in- Knowing when and how to speak up is critical for improving patient experiences without addressing care needs across care outcomes. Many errors occur during transitions in transitions in settingsAmbulatory or multiple providers. The three edi- care, whether between providers, between settings, or unit- tors of this text have carefully researched the competencies to-unit transfers; standardized handoff processes and com- needed for new care management roles, both inpatient and munication can assure care management without outpatient, to coordinate and manage care effectively. interruption. Edited by three experts in ambulatory care who have Competency objectives identifying the knowledge, each served as president of the American