Care Coordination and Transition Management

Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management
Standard 15
Resource Utilization
The RN practicing CCTM utilizes appropriate resources to plan and facilitate services
that are safe, effective, and fiscally responsible.
CCTM nurses:
1. Partner with patients and caregivers to assess individual health care needs and target the resources available to achieve desired outcomes, and assist with access to necessary resources.
2. Utilize appropriate resources to improve population health outcomes.
3. Evaluate resources for potential for harm, complexity of the task, cost effectiveness, and desired outcome
when considering resource allocation.
4. Delegate care to appropriate health care workers when RN level of care is not appropriate, following applicable laws and policies.
5. Identify evidence-based practices when evaluating resource allocation.
6. Modify CCTM practice when necessary to promote optimal interaction between health care consumers,
care providers, and the usage of technology.
7. Educate and support patients and caregivers to become informed consumers about the options, costs,
risks, and benefits of health care services.
Additional Competencies for Nurse Executives, Administrators, and Managers
CCTM nurse executives, administrators, and managers:
1. When allocating resources, evaluate the availability, potential for harm, effectiveness, efficiency, cost, benefits, and the impact on CCTM program and organization.
2. Advocate for resources to include technology that enhances CCTM interventions and outcomes and improves organizational performance.
3. Ensure that written organizational charts delineate nursing authority, accountability, and lines of communication among nurses and other members of the interprofessional team.
4. Provide clearly defined, written descriptions and performance standards for nursing assistive personnel,
outlining the accountability within the scope of practice and their role within the interprofessional team.
5. Plan staffing within organizational guidelines to ensure that sufficient nurses and nursing assistive personnel
are available to deliver high quality CCTM in a safe manner.
6. Evaluate economic factors when choosing innovative CCTM solutions that result in safe, accessible, effective, and efficient practices.
Scope and standards of practice for registered nurses in care coordination and transition management. (2015). ProQuest Ebook Central <a‘’,’_blank’) href=’’ target=’_blank’ style=’cursor: pointer;’></a>
Created from capella on 2021-10-19 01:06:26. Copyright © 2015. American Academy of Ambulatory Care Nursing. All rights reserved.

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