Implementing Care Coordination and Transition Management in a Critical Care Telemetry Unit

This session will present the process for the implementation of care coordination and transition management in a critical care telemetry unit in one urban community hospital. Care Coordination and Transition Management is a new focus and role for the bedside nurse to be competent in care coordination and transition management of patients in the clinical setting. The primary organizations involved in this initiative are the American Academy of Ambulatory Care Nursing (AAACN) and the Medical Surgical Nursing Certification Board which is the organization that offers the certification for this specialty. The preparation and education for both staff nurses and the clinical nurse specialists include extensive education, reading and lecture sessions to become knowledgeable on the concepts and competencies for this role. The key content areas include "advocacy; education and engagement of patients and families; coaching and counseling of patients and families; patient centered care planning; support for self-management; nursing process: proxy for monitoring and evaluation; teamwork and collaboration; cross setting communications and care transitions; population health management; CCTM between acute care and ambulatory care; informatics nursing practice and telehealth nursing practice" (AAACN, 2016). The primary goals of care coordination and transition management are to "improve patient outcomes, enhance quality of care, decrease hospital admissions, decrease health care costs, help patients to navigate the health care system, ensure continuity and seamless transitions between levels of care, and improve the patient's individual experience" (AAACN, 2016). The final step is completion of the certification exam to become certified in care coordination and transition management (CCCTM). Challenges of implementing this program in one critical care telemetry unit in an urban community hospital will be presented as well as strategies for success. Ongoing implementation and management of the program will continue until all nurses are certified including all staff nurses and all advance practice nurses. Evaluation of the implementation process and program will be ongoing.