Advancing Ambulatory Care Nursing Practice: An Innovative Model for Care Coordination and Transition Management

Friday, 26 July 2013: 10:15 AM

Beth Ann Swan, PhD, CRNP, FAAN
Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA
Sheila A. Haas, RN, PhD, FAAN
Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL
Traci Haynes, MSN, RN, BA, CEN
LVM Systems, Mesa, AZ

Learning Objective 1: Describe an innovative model for care coordination and transition management by registered nurses in ambulatory care.

Learning Objective 2: Discuss the required registered nurse competencies for the model.


 The United States healthcare system is challenged in its efforts to effectively manage people with complex health care needs, from a quality, access, and cost perspective.  In ambulatory care clinical practice, the need for care coordination and management of transitions between types of care and settings of care is often overlooked, episodic, follows specialty rather than primary care, and often occurs with no one person responsible or accountable for coordinating care or managing transitions between multiple providers and services.  With over one billion visits annually, ambulatory care is least studied and poorly understood. This situation is expected to increase due to the changes in health care delivery in ambulatory settings making quality, safety, and continuity of care even more challenging.  In acute care settings, much research has focused on improving the transition from hospital to home, examining discharge planning and home visits by advanced practice nurses (APNs).  In primary care settings, research has focused on care coordination by RNs in individuals 65 years and older with multiple co-morbidities and on older adults with depression and multiple chronic diseases. 

,Methods: To respond to this gap, the American Academy of Ambulatory Care Nursing (AAACN) has convened expert panels to identify best evidence

Results:  Delineated and explicated RN care coordination competencies, and developed a structured education intervention 

Conclusion: RN delivery model with a structured education program for care coordination and transition management.