Vision – Volunteers – Value

Care Coordination and Transition Management

The Patient Protection and Affordable Care Act (2010) called for a transformation of the health care system to find innovative ways to manage the complex health needs of Americans, especially the at-risk populations such as patients with multiple chronic conditions, by increasing access to care and managing costs while providing the highest quality of care.

The Institute of Medicine’s (IOM’s) Future of Nursing Report (2011) supports RNs practicing to the full extent of their licensure, promotes RNs achieving higher levels of education, advocates that RNs are full partners in health care redesign, highlights effective workforce planning and policy require better data collection and information, supports expanding opportunities for RNs to lead and diffuse collaborative improvements, and to prepare and enable nurses to lead change to advance health.

The American Academy of Ambulatory Care Nursing (AAACN), an association of 3,000 members, representing over 500,000 RNs practicing in ambulatory care settings, responded to what "the need" the act changes by envisioning and developing the ground-breaking Care Coordination and Transition Management (CCTM) program consisting of several components designed to educate registered nurses (RNs) to coordinate the care of patients and manage their transitions across providers, levels of care, and various care settings.

AAACN recognized the importance in encompassing the continuum of care from the outpatient to hospital settings, and invited the Academy of Medical-Surgical Nurses (AMSN), representing over 600,000 acute care nurses, to participate in this work.

Under the direction of three volunteer leader members, AAACN conducted a translational research study involving four expert panels over the course of two years to develop a model for RN care coordination and transition management and an evidence-based program for CCTM practice.

While developing the CCTM program, AAACN began a collaboration with the AMSN certification partner, the Medical-Surgical Nursing Certification Board (MSNCB), to develop a national certification program to validate the RN’s knowledge and competency in performing CCTM. In addition, Nursing Experts from ambulatory and acute are in the final phase of developing the Scope and Standards of Practice for Professional Care Coordination and Transition Management.

Find out more information about becoming certified through the Care Coordination and Transition Management (CCCTM) certification exam.