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| care coordination and transition management: Care Coordination and Transition Management Core Curriculum Traci S. Haynes, Beth Ann Swan, Haynes Traci, 2014-06-01 The leadership of RNs is critical to solving the puzzle of fragmented patient care. The Care Coordination and Transition Management Core Curriculum is an evidence-based, patient-centered program that covers the dimensions, competencies, and activities of care coordination and transition management. It is designed to help you: Improve patient outcomes; Enhance access to quality care; Decrease hospital re-admissions; Decrease health care costs; Help patients navigate the health care system; Ensure continuity and seamless transitions among levels and settings of care; Work effectively in Patient-Centered Medical Homes and Accountable Care Organizations; Improve the individual patient's experience of care |
| care coordination and transition management: Care Coordination and Transition Management Core Curriculum Sheila Haas, Beth Ann Swan, Traci Haynes, 2019-08 The Care Coordination and Transition Management (CCTM) Core Curriculum (2nd Edition) offers content developed by experts that will provide RNs with the knowledge, skills, and attitudes to practice in all health care settings today and tomorrow. The CCTM Core Curriculum will help RNs to: practice at the top of their license and become certified in CCTM; enhance interprofessional collaboration and communication; enhance safety and quality of patient outcomes; consistently provide best evidence-based assessments and interventions; gain expertise in population health management; tap into nurse-sensitive outcome metrics; enhance RN informatics knowledge and skills; use big data effectively to manage populations; enhance access to high-quality care; decrease ED use and readmission; decrease health care costs; and expand knowledge of resources and apps used in CCTM. |
| care coordination and transition management: Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management American Academy of Ambulatory Care Nursing, 2015-12-01 This document is an evolution of the American Academy of Ambulatory Care Nursing'sbody of work related Care Coordination and Transition Management (CCTM) and a major step forward for nurses in CCTM roles. It is the first statement of the scope andstandards of practice for RNs engaged in CCTM. This document may be used as a tool to advance professional CCTM nursing practice, patientand population health, andthe performance outcomes of health care institutions. |
| care coordination and transition management: Care Coordination and Transition Management (CCTM) Review Questions American Academy of Ambulatory Care Nursing, 2016-05-15 Welcome to the Care Coordination and Transition Management (CCTM) Review Questions published by the American Academy of Ambulatory Care Nursing (AAACN). This set of mock test items is designed to assist nurses in assessing their knowledge of the practice of care coordination and transition management, and to prepare for the Certified in Care Coordination and Transition Management (CCCTM) exam provided by the Medical-Surgical Nursing Certification Board (MSNCB) in collaboration with AAACN. Professional nurses should take every opportunity to advance their expertise, skills, and knowledge, and use tools such as this publication to assess their knowledge gaps and learn from studying the answers. |
| care coordination and transition management: Closing the Quality Gap Kaveh G. Shojania, 2004 |
| care coordination and transition management: Core Curriculum for Ambulatory Care Nursing Candia Baker Laughlin, 2013-01-01 The Core Curriculum for Ambulatory Care Nursing (3rd Edition) has been organized and expanded to address the educational needs of nurses new to the specialty and those with experience, as well as to provide a review for those who seek specialty certification as an ambulatory care nurse. |
| care coordination and transition management: Care Coordination Gerri Lamb, Robin Purdy Newhouse, 2018 Care Coordination : A Blueprint for Action for RNs, [the sequel to the ANA's Care Coordination: the Game Changer] helps today’s nurses reclaim this critical practice domain. It explores key issues in care coordination and offers timely, strategic actions nurses can take right now to identify opportunities and overcome barriers. It also includes critical resources for nurse care coordinators.. It also includes critical resources for nurse care coordinators. This book will help you: Understand care coordination - past, present, and future - as well as the professional and practice environments in which it occurs; define the activities associated with effective care coordination; recognize the significant need for care coordination and opportunities for nurses Identify and explore issues pivotal to creating new inroads for nursing to adapt and advance this important work; expand the capacity of nurses to deliver care coordination and develop new and better care coordination models. Learn how you and your fellow nurses can advance your important role in care coordination in the current and emerging health care environment. -- Publisher's website. |
| care coordination and transition management: Advances in Patient Safety Kerm Henriksen, 2005 v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products. |
| care coordination and transition management: Care Coordination Gerri Lamb, 2014 Care coordination has always been a primary duty of nursing. This book, edited by Gerri Lamb Ph.D., RN, FAAN and with text from 23 contributing writers, offers comprehensive insights, case studies and strategies to advance nursing's role in care coordination and healthcare transformation. |
| care coordination and transition management: Connecting Care for Patients: Interdisciplinary Care Transitions and Collaboration Barbara Katz, 2018-10-29 Connecting Care for Patients: Interdisciplinary Care Transitions and Collaboration addresses practical strategies for creating connected, seamless, and transparent health care for patients in settings outside of the hospital. It presents antidotes to healthcare fragmentation caused by inefficient care, patient safety problems, patient dissatisfaction, and higher costs. The text focuses on clinical case management, interdisciplinary referrals and conferencing, cross functional team meetings, tracking patients in value-based purchasing programs, inpatient liaison visits, structured collaboration with physician groups, and referral sources and development of clinical community networking groups. Further, it explores tools for patient self-management support, effective integration of technology, family caregiver engagement, and techniques for addressing health disparities and other high-risk care gaps. |
| care coordination and transition management: Health Care Transition Albert C. Hergenroeder, Constance M. Wiemann, 2018-05-03 This comprehensive book thoroughly addresses all aspects of health care transition of adolescents and young adults with chronic illness or disability; and includes the framework, tools and case-based examples needed to develop and evaluate a Health Care Transition (HCT) planning program that can be implemented regardless of a patient’s disease or disability. Health Care Transition: Building a Program for Adolescents and Young Adults with Chronic Illness and Disability is a uniquely inclusive resource, incorporating youth/young adult, caregiver, and pediatric and adult provider voices and perspectives. Part I of the book opens by defining Health Care Transition, describing the urgent need for comprehensive transition planning, barriers to HCT and then offering a framework for developing and evaluating health care transition programs. Part II focuses on the anatomic and neuro-chemical changes that occur in the brain during adolescence and young adulthood, and how they affect function and behavior. Part III covers the perspectives of important participants in the HCT transition process – youth and young adults, caregivers, and both pediatric and adult providers. Each chapter in Part IV addresses a unique aspect of developing HCT programs. Part V explores various examples of successful transition from the perspective of five key participants in the transition process - patients, caregivers, pediatric providers, adult providers and third party payers. Related financial matters are covered in part VI, while Part VII explores special issues such as HCT and the medical home, international perspectives, and potential legal issues. Models of HCT programs are presented in Part VIII, utilizing an example case study. Representing perspectives from over 75 authors and more than 100 medical centers in North America and Europe, Health Care Transition: Building a Program for Adolescents and Young Adults with Chronic Illness and Disability is an ideal resource for any clinician, policy maker, caregiver, or hospitalist working with youth in transition. |
| care coordination and transition management: The Future of Nursing Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011-02-08 The Future of Nursing explores how nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system. At more than 3 million in number, nurses make up the single largest segment of the health care work force. They also spend the greatest amount of time in delivering patient care as a profession. Nurses therefore have valuable insights and unique abilities to contribute as partners with other health care professionals in improving the quality and safety of care as envisioned in the Affordable Care Act (ACA) enacted this year. Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States. To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates. Furthermore, regulatory and institutional obstacles-including limits on nurses' scope of practice-should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care. In this book, the Institute of Medicine makes recommendations for an action-oriented blueprint for the future of nursing. |
| care coordination and transition management: Interprofessional Care Coordination for Pediatric Autism Spectrum Disorder Maryellen Brunson McClain, Jeffrey D. Shahidullah, Katherine R. Mezher, 2020-06-23 This book addresses the importance and relevance of interprofessional care coordination for children and youth with autism spectrum disorder (ASD). It covers the role of interprofessional collaborations across various settings for multiple service provision purposes. The volume examines interprofessional collaboration among professionals across such broad issues as screening, evaluation, intervention, and overall care management of ASD. In addition, the book explores more narrowly focused issues, such as providing transition services during early childhood and young adulthood, culturally responsive practice and advocacy issues for individuals with ASD from diverse backgrounds, and providing care for individuals with ASD and co-occurring trauma. Finally, the book concludes with the editors’ recommendations for future directions in interprofessional care for pediatric ASD. Topics featured in this book include: Autism screening tools and interdisciplinary coordination of the processes. Dell Children’s (S)TAAR Model of Early Autism Assessment. The Early Start Denver Model (ESDM). Transition from early schooling for youth with ASD. Postsecondary and vocational opportunities for youth with autism. Transitioning from pediatric to adult medical systems. International perspectives in coordinated care for individuals with ASD. Psychopharmacology of ASD. Interprofessional Care Coordination for Pediatric Autism Spectrum Disorder is an essential resource for researchers, clinicians and professionals, and graduate students in clinical child and school psychology, social work, behavioral therapy and related disciplines, including clinical medicine, clinical nursing, counseling, speech and language pathology, and special education. |
| care coordination and transition management: Promoting the Health of the Community Julie Ann St. John, Susan L. Mayfield-Johnson, Wandy D. Hernández-Gordon, 2021-03-22 Community health workers (CHWs) are an increasingly important member of the healthcare and public health professions who help build primary care capacity. Yet, in spite of the exponential growth of CHW interventions, CHW training programs, and CHW certification and credentialing by state agencies, a gap persists in the literature regarding current CHW roles and skills, scope of practice, CHW job settings, and national standards. This collection of contributions addresses this gap by providing information, in a single volume, about CHWs, the roles CHWs play as change agents in their communities, integration of CHWs into healthcare teams, and support and recognition of the CHW profession. The book supports the CHW definition as defined by the American Public Health Association (APHA), Community Health Worker Section (2013), which states, “A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” The scope of the text follows the framework of the nationally recognized roles of CHWs that came out of a national consensus-building project called “The Community Health Worker (CHW) Core Consensus (C3) Project”. Topics explored among the chapters include: Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems Care Coordination, Case Management, and System Navigation Advocating for Individuals and Communities Building Individual and Community Capacity Implementing Individual and Community Assessments Participating in Evaluation and Research Uniting the Workforce: Building Capacity for a National Association of Community Health Workers Promoting the Health of the Community is a must-have resource for CHWs, those interested in CHW scope of practice and/or certification/credentialing, anyone interested in becoming a CHW, policy-makers, CHW payer systems, CHW supervisors, CHW employers, CHW instructors/trainers, CHW advocates/supporters, and communities served by CHWs. |
| care coordination and transition management: Improving the Quality of Health Care for Mental and Substance-Use Conditions Institute of Medicine, Board on Health Care Services, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, 2006-03-29 Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€use conditions will benefit from this guide to achieving better care. |
| care coordination and transition management: Code of Ethics for Nurses with Interpretive Statements American Nurses Association, 2001 Pamphlet is a succinct statement of the ethical obligations and duties of individuals who enter the nursing profession, the profession's nonnegotiable ethical standard, and an expression of nursing's own understanding of its commitment to society. Provides a framework for nurses to use in ethical analysis and decision-making. |
| care coordination and transition management: Transitions Theory Afaf I. Meleis, PhD, DrPS (hon), FAAN, 2010-02-17 It is very exciting to see all of these studies compiled in one book. It can be read sequentially or just for certain transitions. It also can be used as a template for compilation of other concepts central to nursing and can serve as a resource for further studies in transitions. It is an excellent addition to the nursing literature. Score: 95, 4 Stars. --Doody's Understanding and recognizing transitions are at the heart of health care reform and this current edition, with its numerous clinical examples and descriptions of nursing interventions, provides important lessons that can and should be incorporated into health policy. It is a brilliant book and an important contribution to nursing theory. Kathleen Dracup, RN, DNSc Dean and Professor, School of Nursing University of California San Francisco Afaf Meleis, the dean of the University of Pennsylvania School of Nursing, presents for the first time in a single volume her original transitions theory that integrates middle-range theory to assist nurses in facilitating positive transitions for patients, families, and communities. Nurses are consistently relied on to coach and support patients going through major life transitions, such as illness, recovery, pregnancy, old age, and many more. A collection of over 50 articles published from 1975 through 2007 and five newly commissioned articles, Transitions Theory covers developmental, situational, health and illness, organizational, and therapeutic transitions. Each section includes an introduction written by Dr. Meleis in which she offers her historical and practical perspective on transitions. Many of the articles consider the transitional experiences of ethnically diverse patients, women, the elderly, and other minority populations. Key Topics Discussed: Situational transitions, including discharge and relocation transitions (hospital to home, stroke recovery) and immigration transitions (psychological adaptation and impact of migration on family health) Educational transitions, including professional transitions (from RN to BSN and student to professional) Health and illness transitions, including self-care post heart failure, living with chronic illness, living with early dementia, and accepting palliative care Organization transitions, including role transitions from acute care to collaborative practice, and hospital to community practice Nursing therapeutics models of transition, including role supplementation models and debriefing models |
| care coordination and transition management: Nutrition and Healthy Aging in the Community Institute of Medicine, Food and Nutrition Board, 2012-06-15 The U.S. population of older adults is predicted to grow rapidly as baby boomers (those born between 1946 and 1964) begin to reach 65 years of age. Simultaneously, advancements in medical care and improved awareness of healthy lifestyles have led to longer life expectancies. The Census Bureau projects that the population of Americans 65 years of age and older will rise from approximately 40 million in 2010 to 55 million in 2020, a 36 percent increase. Furthermore, older adults are choosing to live independently in the community setting rather than residing in an institutional environment. Furthermore, the types of services needed by this population are shifting due to changes in their health issues. Older adults have historically been viewed as underweight and frail; however, over the past decade there has been an increase in the number of obese older persons. Obesity in older adults is not only associated with medical comorbidities such as diabetes; it is also a major risk factor for functional decline and homebound status. The baby boomers have a greater prevalence of obesity than any of their historic counterparts, and projections forecast an aging population with even greater chronic disease burden and disability. In light of the increasing numbers of older adults choosing to live independently rather than in nursing homes, and the important role nutrition can play in healthy aging, the Institute of Medicine (IOM) convened a public workshop to illuminate issues related to community-based delivery of nutrition services for older adults and to identify nutrition interventions and model programs. Nutrition and Healthy Aging in the Community summarizes the presentations and discussions prepared from the workshop transcript and slides. This report examines nutrition-related issues of concern experienced by older adults in the community including nutrition screening, food insecurity, sarcopenic obesity, dietary patterns for older adults, and economic issues. This report explores transitional care as individuals move from acute, subacute, or chronic care settings to the community, and provides models of transitional care in the community. This report also provides examples of successful intervention models in the community setting, and covers the discussion of research gaps in knowledge about nutrition interventions and services for older adults in the community. |
| care coordination and transition management: The Healthcare Imperative Institute of Medicine, Roundtable on Evidence-Based Medicine, 2011-01-17 The United States has the highest per capita spending on health care of any industrialized nation but continually lags behind other nations in health care outcomes including life expectancy and infant mortality. National health expenditures are projected to exceed $2.5 trillion in 2009. Given healthcare's direct impact on the economy, there is a critical need to control health care spending. According to The Health Imperative: Lowering Costs and Improving Outcomes, the costs of health care have strained the federal budget, and negatively affected state governments, the private sector and individuals. Healthcare expenditures have restricted the ability of state and local governments to fund other priorities and have contributed to slowing growth in wages and jobs in the private sector. Moreover, the number of uninsured has risen from 45.7 million in 2007 to 46.3 million in 2008. The Health Imperative: Lowering Costs and Improving Outcomes identifies a number of factors driving expenditure growth including scientific uncertainty, perverse economic and practice incentives, system fragmentation, lack of patient involvement, and under-investment in population health. Experts discussed key levers for catalyzing transformation of the delivery system. A few included streamlined health insurance regulation, administrative simplification and clarification and quality and consistency in treatment. The book is an excellent guide for policymakers at all levels of government, as well as private sector healthcare workers. |
| care coordination and transition management: Nurses Contributions to Quality Health Outcomes Marianne Baernholdt, Diane K. Boyle, 2021-05-04 This comprehensive book organizes the components of quality and safety outcomes, within a framework developed by expert nurses. Such a framework is missing in existing books on quality and safety in health care, and the concepts of nursing and organizational outcomes are often overlooked. This book fills this gap by exploring and expanding the various features of the Quality Health Outcomes Model (QHOM) and its four main concepts of System, Client, Interventions, and Outcomes. Using a broad and comprehensive approach, the authors identify the most current empirical evidence and concepts in the nursing field to provide an up-to-date understanding of the QHOM’s four concepts and their interrelations. New concepts include (a) systems concepts of turbulence and complexity of workflow and use of the electronic health record to support clinical workflow; (b) client concepts of social determinants of health, health literacy, and chronicity; (c) intervention concepts of interprofessional practice, nursing care processes including unfinished care, and care coordination; (d) outcome concepts related to nursing and the organization in addition to patient outcomes that includes the patients’ experience. The ideas, approaches, and evidence are provided by a team of experienced researchers, practitioners, and leaders. The author team presents an updated, state-of-art view of how system, client, and interventions affect client, nurse, and organizational outcomes. This book will appeal to researchers, clinicians, and researchers interested in healthcare quality and in particular nurses and nursing students in administration, research, and practice. |
| care coordination and transition management: Health Professions Education Institute of Medicine, Board on Health Care Services, Committee on the Health Professions Education Summit, 2003-07-01 The Institute of Medicine study Crossing the Quality Chasm (2001) recommended that an interdisciplinary summit be held to further reform of health professions education in order to enhance quality and patient safety. Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education. These core competencies include patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. This book recommends a mix of approaches to health education improvement, including those related to oversight processes, the training environment, research, public reporting, and leadership. Educators, administrators, and health professionals can use this book to help achieve an approach to education that better prepares clinicians to meet both the needs of patients and the requirements of a changing health care system. |
| care coordination and transition management: Managing Transitions (25th anniversary edition) William Bridges, Susan Bridges, 2017-01-10 The business world is constantly transforming. When restructures, mergers, bankruptcies, and layoffs hit the workplace, employees and managers naturally find the resulting situational shifts to be challenging. But the psychological transitions that accompany them are even more stressful. Organizational transitions affect people; it is always people, rather than a company, who have to embrace a new situation and carry out the corresponding change. As veteran business consultant William Bridges explains, transition is successful when employees have a purpose, a plan, and a part to play. This indispensable guide is now updated to reflect the challenges of today's ever-changing, always-on, and globally connected workplaces. Directed at managers on all rungs of the corporate ladder, this expanded edition of the classic bestseller provides practical, step-by-step strategies for minimizing disruptions and navigating uncertain times. |
| care coordination and transition management: Introduction to Care Coordination and Nursing Management Laura J. Fero, Charlotte Anne Herrick, Jie Hu (Ph. D.), 2011 A new and updated version of this best-selling resource! Jones and Bartlett Publisher's 2011 Nurse's Drug Handbook is the most up-to-date, practical, and easy-to-use nursing drug reference! It provides: Accurate, timely facts on hundreds of drugs from abacavir sulfate to Zyvox; Concise, consistently formatted drug entries organized alphabetically; No-nonsense writing style that speaks your language in terms you use everyday; Index of all generic, trade, and alternate drug names for quick reference. It has all the vital information you need at your fingertips: Chemical and therapeutic classes, FDA pregnancy risk category and controlled substance schedule; Indications and dosages, as well as route, onset, peak, and duration information; Incompatibilities, contraindications; interactions with drugs, food, and activities, and adverse reactions; Nursing considerations, including key patient-teaching points; Vital features include mechanism-of-action illustrations showing how drugs at the cellular, tissue, or organ levels and dosage adjustments help individualize care for elderly patients, patients with renal impairment, and others with special needs; Warnings and precautions that keep you informed and alert. |
| care coordination and transition management: Ask a Manager Alison Green, 2018-05-01 From the creator of the popular website Ask a Manager and New York’s work-advice columnist comes a witty, practical guide to 200 difficult professional conversations—featuring all-new advice! There’s a reason Alison Green has been called “the Dear Abby of the work world.” Ten years as a workplace-advice columnist have taught her that people avoid awkward conversations in the office because they simply don’t know what to say. Thankfully, Green does—and in this incredibly helpful book, she tackles the tough discussions you may need to have during your career. You’ll learn what to say when • coworkers push their work on you—then take credit for it • you accidentally trash-talk someone in an email then hit “reply all” • you’re being micromanaged—or not being managed at all • you catch a colleague in a lie • your boss seems unhappy with your work • your cubemate’s loud speakerphone is making you homicidal • you got drunk at the holiday party Praise for Ask a Manager “A must-read for anyone who works . . . [Alison Green’s] advice boils down to the idea that you should be professional (even when others are not) and that communicating in a straightforward manner with candor and kindness will get you far, no matter where you work.”—Booklist (starred review) “The author’s friendly, warm, no-nonsense writing is a pleasure to read, and her advice can be widely applied to relationships in all areas of readers’ lives. Ideal for anyone new to the job market or new to management, or anyone hoping to improve their work experience.”—Library Journal (starred review) “I am a huge fan of Alison Green’s Ask a Manager column. This book is even better. It teaches us how to deal with many of the most vexing big and little problems in our workplaces—and to do so with grace, confidence, and a sense of humor.”—Robert Sutton, Stanford professor and author of The No Asshole Rule and The Asshole Survival Guide “Ask a Manager is the ultimate playbook for navigating the traditional workforce in a diplomatic but firm way.”—Erin Lowry, author of Broke Millennial: Stop Scraping By and Get Your Financial Life Together |
| care coordination and transition management: Health Care Comes Home National Research Council, Division of Behavioral and Social Sciences and Education, Board on Human-Systems Integration, Committee on the Role of Human Factors in Home Health Care, 2011-06-22 In the United States, health care devices, technologies, and practices are rapidly moving into the home. The factors driving this migration include the costs of health care, the growing numbers of older adults, the increasing prevalence of chronic conditions and diseases and improved survival rates for people with those conditions and diseases, and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as in its quality and cost. Health Care Comes Home reviews the state of current knowledge and practice about many aspects of health care in residential settings and explores the short- and long-term effects of emerging trends and technologies. By evaluating existing systems, the book identifies design problems and imbalances between technological system demands and the capabilities of users. Health Care Comes Home recommends critical steps to improve health care in the home. The book's recommendations cover the regulation of health care technologies, proper training and preparation for people who provide in-home care, and how existing housing can be modified and new accessible housing can be better designed for residential health care. The book also identifies knowledge gaps in the field and how these can be addressed through research and development initiatives. Health Care Comes Home lays the foundation for the integration of human health factors with the design and implementation of home health care devices, technologies, and practices. The book describes ways in which the Agency for Healthcare Research and Quality (AHRQ), the U.S. Food and Drug Administration (FDA), and federal housing agencies can collaborate to improve the quality of health care at home. It is also a valuable resource for residential health care providers and caregivers. |
| care coordination and transition management: Surgical Patient Care Juan A. Sanchez, Paul Barach, Julie K. Johnson, Jeffrey P. Jacobs, 2017-05-29 This book focuses exclusively on the surgical patient and on the perioperative environment with its unique socio-technical and cultural issues. It covers preoperative, intraoperative, and postoperative processes and decision making and explores both sharp-end and latent factors contributing to harm and poor quality outcomes. It is intended to be a resource for all healthcare practitioners that interact with the surgical patient. This book provides a framework for understanding and addressing many of the organizational, technical, and cultural aspects of care to one of the most vulnerable patients in the system, the surgical patient. The first section presents foundational principles of safety science and related social science. The second exposes barriers to achieving optimal surgical outcomes and details the various errors and events that occur in the perioperative environment. The third section contains prescriptive and proactive tools and ways to eliminate errors and harm. The final section focuses on developing continuous quality improvement programs with an emphasis on safety and reliability. Surgical Patient Care: Improving Safety, Quality and Value targets an international audience which includes all hospital, ambulatory and clinic-based operating room personnel as well as healthcare administrators and managers, directors of risk management and patient safety, health services researchers, and individuals in higher education in the health professions. It is intended to provide both fundamental knowledge and practical information for those at the front line of patient care. The increasing interest in patient safety worldwide makes this a timely global topic. As such, the content is written for an international audience and contains materials from leading international authors who have implemented many successful programs. |
| care coordination and transition management: Consumer Informatics and Digital Health Margo Edmunds, Christopher Hass, Erin Holve, 2019-01-17 This unique collection synthesizes insights and evidence from innovators in consumer informatics and highlights the technical, behavioral, social, and policy issues driving digital health today and in the foreseeable future. Consumer Informatics and Digital Health presents the fundamentals of mobile health, reviews the evidence for consumer technology as a driver of health behavior change, and examines user experience and real-world technology design challenges and successes. Additionally, it identifies key considerations for successfully engaging consumers in their own care, considers the ethics of using personal health information in research, and outlines implications for health system redesign. The editors’ integrative systems approach heralds a future of technological advances tempered by best practices drawn from today’s critical policy goals of patient engagement, community health promotion, and health equity. Here’s the inside view of consumer health informatics and key digital fields that students and professionals will find inspiring, informative, and thought-provoking. Included among the topics: • Healthcare social media for consumer informatics • Understanding usability, accessibility, and human-centered design principles • Understanding the fundamentals of design for motivation and behavior change • Digital tools for parents: innovations in pediatric urgent care • Behavioral medicine and informatics in the cancer community • Content strategy: writing for health consumers on the web • Open science and the future of data analytics • Digital approaches to engage consumers in value-based purchasing Consumer Informatics and Digital Health takes an expansive view of the fields influencing consumer informatics and offers practical case-based guidance for a broad range of audiences, including students, educators, researchers, journalists, and policymakers interested in biomedical informatics, mobile health, information science, and population health. It has as much to offer readers in clinical fields such as medicine, nursing, and psychology as it does to those engaged in digital pursuits. |
| care coordination and transition management: Nursing Case Management Elaine Cohen, Toni G. Cesta, 2004-08-26 This classic resource offers complete coverage of nursing case management - from theoretical background and historical perspective to practical applications and how the field is changing to meet the challenges of today's health care environment. It focuses on the implementation of various case management models used throughout the United States and abroad. Key topics include the impact of public policy on health care; understanding the effects of health care reimbursement and its application at the patient level; throughput and capacity management; the impact of the revenue cycle; compliance and regulatory issues; and principles needed to improve case manager-client interaction. This helpful resource is designed to help nurse case managers assess their organization's readiness for case management, prepare and implement a plan to achieve necessary improvements and evaluate the plan's success. Includes numerous proven case management models currently being used in institutions across the country Organized to take the nursing case manager on a journey from the historical development of nursing case management to the successful implementation of a case management program Offers detailed guidance for planning, implementing, and evaluating a case management program Outlines the planning process with information on key topics such as analysis of the organization, the role of the organization's members, selection criteria for new case managers, case management education, credentialing, and partnerships Features guidelines for implementing a case management program with information on ethical issues, technology, compliance, and regulatory issues Addresses the evaluation component of developing and implementing a case management program by presenting information on outcomes, research, documentation, continuous quality improvement, measuring cost effectiveness, care continuum, and evidence-based practice Presents acute care and community based models of case management Highlights the evolution of collaborative models of case management, addressing key elements of joint decision-making, shared accountability, and interdisciplinary systems of care Addresses health care delivery through case management and public policy by presenting current legislative issues and their affect on both health care reimbursement and the application of care at the patient level Presents the insights, experiences, and advice of nursing administrators who have researched and successfully implemented nursing case management programs in various facilities |
| care coordination and transition management: Perspectives in Ambulatory Care Nursing Caroline Coburn, Deena Gilland, Beth Ann Swan, 2021-01-15 The perfect ambulatory care primer for undergraduate nursing students or practicing nurses transitioning from acute care settings, Perspectives in Ambulatory Care delivers expert insight into this evolving specialty and familiarizes readers with the top issues and trends they’ll encounter in ambulatory nursing practice. This authoritative resource clarifies the distinctions between ambulatory care and acute care, details the wide variety of ambulatory care roles and settings and demonstrates the growing impact and importance of nurses outside the hospital setting to help readers confidently meet the challenges of a changing healthcare landscape and succeed in this critical area of care. |
| care coordination and transition management: Handbook Integrated Care Volker Amelung, Viktoria Stein, Esther Suter, Nicholas Goodwin, Ellen Nolte, Ran Balicer, 2022-07-27 This handbook shares profound insights into the main principles and concepts of integrated care. It offers a multi-disciplinary perspective with a focus on patient orientation, efficiency, and quality by applying widely recognized management approaches to the field of healthcare. The handbook also highlights international best practices and shows how integrated care can work in various health systems. In the majority of health systems around the world, the delivery of healthcare and social care is characterised by fragmentation and complexity. Consequently, much of the recent international discussion in the fields of health policy and health management has focused on the topic of integrated care. “Integrated” acknowledges the complexity of patients’ needs and aims to meet them by taking into account both health and social care aspects. Changing and improving processes in a coordinated way is at the heart of this approach. The second edition offers new chapters on people-centredness, complexity theories and evaluation methods, additional management tools and a wealth of experiences from different countries and localities. It is essential reading both for health policymakers seeking inspiration for legislation and for practitioners involved in the management of public health services who want to learn from good practice. |
| care coordination and transition management: The 1st Annual Crossing the Quality Chasm Summit Institute of Medicine, Board on Health Care Services, Committee on the Crossing the Quality Chasm: Next Steps Toward a New Health Care System, 2004-09-13 In January 2004, the Institute of Medicine (IOM) hosted the 1st Annual Crossing the Quality Chasm Summit, convening a group of national and community health care leaders to pool their knowledge and resources with regard to strategies for improving patient care for five common chronic illnesses. This summit was a direct outgrowth and continuation of the recommendations put forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century. The summit's purpose was to offer specific guidance at both the community and national levels for overcoming the challenges to the provision of high-quality care articulated in the Quality Chasm report and for moving closer to achievement of the patient-centerd health care system envisioned therein. |
| care coordination and transition management: Leadership and Nursing Care Management Diane Huber, 2010 This new edition addresses basic issues in nurse management such as law and ethics, staffing and scheduling, delegation, cultural considerations and management of time and stress. It also provides readers with the core concepts that separate adequate and exceptional nurse managers. |
| care coordination and transition management: Transitions William Bridges, 2004-08-11 The best-selling guide for coping with changes in life and work, named one of the 50 all-time best books in self-help and personal development Whether you choose it or it is thrust upon you, change brings both opportunities and turmoil. Since Transitions was first published, this supportive guide has helped hundreds of thousands of readers cope with these issues by providing an elegantly simple yet profoundly insightful roadmap of the transition process. With the understanding born of both personal and professional experience, William Bridges takes readers step by step through the three stages of any transition: The Ending, The Neutral Zone, and, eventually, The New Beginning. Bridges explains how each stage can be understood and embraced, leading to meaningful and productive movement into a hopeful future. With a new introduction highlighting how the advice in the book continues to apply and is perhaps even more relevant today, and a new chapter devoted to change in the workplace, Transitions will remain the essential guide for coping with the one constant in life: change. |
| care coordination and transition management: Patient Safety and Quality Ronda Hughes, 2008 Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/ |
| care coordination and transition management: It's Not Complicated Rick Nason, 2017-05-08 In the new knowledge economy, traditional modes of thinking are no longer effective. Compartmentalizing problems and solutions and assuming everything can be solved with the right formula can no longer keep pace with the radical changes occurring daily in the modern business world. It’s Not Complicated offers a paradigm shift for business professionals looking for simplified solutions to complex problems. In his straightforward and highly engaging style, Rick Nason introduces the principles of “complexity thinking” which empower managers to understand, correlate, and explain a diverse range of business phenomena. For example, why some new products go viral while others remain unnoticed, how office cliques develop despite collaborative work policies and spaces, how economic bubbles form, and how an unknown retiree foiled one of the most carefully planned product launches ever with a single letter to the editor of his local newspaper. Rather than consider complicated and complex as interchangeable terms, Rick Nason explains what complexity is, how it arises, and the errors in solving complex situations with complicated thinking. It’s Not Complicated provides managers with fresh, counterintuitive, and actionable models for dealing with challenging business problems. |
| care coordination and transition management: CMSA's Integrated Case Management Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, Rebecca Perez, MSN, RN, CCM, FCM, Corine Latour, PhD, RN, 2018-01-28 Written by case managers for case managers, this reference manual for nurses and other health professionals presents a CMSA tested approach towards systematically integrating physical and mental health case management principles and assessment tools. Since the health care field has undergone major changes such as the passing of the Patient Protection and Affordable Care Act, Mental Health Parity, Transition of Care & Chronic Care Management and the Medicare Act and CHIP Authorization Act (MACRA), health care workers must competently know how to integrate those new regulations, describe alternative payment options, and implement requirements for greater patient and family assessment, care planning, and care coordination in their practice. CMSA’s Integrated Case Management delves into the role of the case manager and unpacks how case managers assess and treat complex patients. These are patients who may be challenged with medical and behavioral conditions, poor access to care services, as well as chronic illnesses and disabilities, and require multidisciplinary care to regain health and function. With a wealth of information on regulatory requirements, new models of care, integration of services, digital and telemedicine, and new performance measures that are clearly defined for nurses in nursing terminology, chapters outline the steps needed to begin, implement, and use the interventions of the Integrated Case Management approach. All content aligns with the newly revised 2017 Model Care Act, CMSA Standards of Practice 2016 as well as the CMSA Core Curriculum for Case Management Third Edition. |
| care coordination and transition management: CPT 2021 Professional Edition American Medical Association, 2020-09-17 CPT® 2021 Professional Edition is the definitive AMA-authored resource to help health care professionals correctly report and bill medical procedures and services. Providers want accurate reimbursement. Payers want efficient claims processing. Since the CPT® code set is a dynamic, everchanging standard, an outdated codebook does not suffice. Correct reporting and billing of medical procedures and services begins with CPT® 2021 Professional Edition. Only the AMA, with the help of physicians and other experts in the health care community, creates and maintains the CPT code set. No other publisher can claim that. No other codebook can provide the official guidelines to code medical services and procedures properly. FEATURES AND BENEFITS The CPT® 2021 Professional Edition codebook covers hundreds of code, guideline and text changes and features: CPT® Changes, CPT® Assistant, and Clinical Examples in Radiology citations -- provides cross-referenced information in popular AMA resources that can enhance your understanding of the CPT code set E/M 2021 code changes - gives guidelines on the updated codes for office or other outpatient and prolonged services section incorporated A comprehensive index -- aids you in locating codes related to a specific procedure, service, anatomic site, condition, synonym, eponym or abbreviation to allow for a clearer, quicker search Anatomical and procedural illustrations -- help improve coding accuracy and understanding of the anatomy and procedures being discussed Coding tips throughout each section -- improve your understanding of the nuances of the code set Enhanced codebook table of contents -- allows users to perform a quick search of the codebook's entire content without being in a specific section Section-specific table of contents -- provides users with a tool to navigate more effectively through each section's codes Summary of additions, deletions and revisions -- provides a quick reference to 2020 changes without having to refer to previous editions Multiple appendices -- offer quick reference to additional information and resources that cover such topics as modifiers, clinical examples, add-on codes, vascular families, multianalyte assays and telemedicine services Comprehensive E/M code selection tables -- aid physicians and coders in assigning the most appropriate evaluation and management codes Adhesive section tabs -- allow you to flag those sections and pages most relevant to your work More full color procedural illustrations Notes pages at the end of every code set section and subsection |
| care coordination and transition management: Crossing the Quality Chasm Institute of Medicine, Committee on Quality of Health Care in America, 2001-07-19 Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change. |
| care coordination and transition management: Annual Review of Nursing Research, Volume 25, 2007 , 2007-06-11 This 25th anniversary edition of the Annual Review of Nursing Research is focused on nursing science in vulnerable populations. Identified as a priority in the nursing discipline, vulnerable populations are discussed in terms of the development of nursing science, diverse approaches in building the state of the science research, integrating biologic methods in the research, and research in reducing health disparities. Topics include: Measurement issues Prevention of infectious diseases among vulnerable populations Genomics and proteomics methodologies for research Promoting culturally appropriate interventions Community-academic research partnerships with vulnerable populations Vulnerable populations in Thailand: women living with HIV/AIDS As in all volumes of the Annual Reviews, leading nurse researchers provide students, other researchers, and clinicians with the foundations for evidence-based practice and further research. |
| care coordination and transition management: Engineering a Learning Healthcare System National Academy of Engineering, Institute of Medicine, 2011-07-14 Improving our nation's healthcare system is a challenge which, because of its scale and complexity, requires a creative approach and input from many different fields of expertise. Lessons from engineering have the potential to improve both the efficiency and quality of healthcare delivery. The fundamental notion of a high-performing healthcare system-one that increasingly is more effective, more efficient, safer, and higher quality-is rooted in continuous improvement principles that medicine shares with engineering. As part of its Learning Health System series of workshops, the Institute of Medicine's Roundtable on Value and Science-Driven Health Care and the National Academy of Engineering, hosted a workshop on lessons from systems and operations engineering that could be applied to health care. Building on previous work done in this area the workshop convened leading engineering practitioners, health professionals, and scholars to explore how the field might learn from and apply systems engineering principles in the design of a learning healthcare system. Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary focuses on current major healthcare system challenges and what the field of engineering has to offer in the redesign of the system toward a learning healthcare system. |
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