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data-target=""> <a class="we-mega-menu-li" title="" href="/practice-resources" target=""> Practice Resources </a> <div class="we-mega-menu-submenu megamenu-practice-resources" data-element-type="we-mega-menu-submenu" data-submenu-width="800" data-class="megamenu-practice-resources" style="width: 800px"> <div class="we-mega-menu-submenu-inner"> <div class="we-mega-menu-row" data-element-type="we-mega-menu-row" data-custom-row="0"> <div class="we-mega-menu-col span4" data-element-type="we-mega-menu-col" data-width="4" data-block="" data-blocktitle="0" data-hidewhencollapse="" data-class=""> <ul class="nav nav-tabs subul"> <li class="we-mega-menu-li dropdown-menu we-mega-menu-group" data-level="1" data-element-type="we-mega-menu-li" description="" data-id="9ffa5f7f-2f6d-4f45-9a25-1fff83818dff" data-submenu="1" hide-sub-when-collapse="" data-group="1" data-class="" data-icon="" data-caption="" data-alignsub="" data-target=""> <a href='#' data-drupal-link-system-path="<front>" 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data-submenu="0" hide-sub-when-collapse="" data-group="0" data-class="" data-icon="" data-caption="" data-alignsub="" data-target=""> <a class="we-mega-menu-li" title="" href="/practice-resources/supporting-and-connecting-you-during-covid-19" target=""> Information & Resources </a> </li> <li class="we-mega-menu-li dropdown-menu" data-level="2" data-element-type="we-mega-menu-li" description="" data-id="53e37acf-4adc-4e55-af84-59868756b3b5" data-submenu="1" hide-sub-when-collapse="" data-group="0" data-class="" data-icon="" data-caption="" data-alignsub="" data-target=""> <a class="we-mega-menu-li" title="" href="/practice-resources/ambulatory-care-nursing/what-ambulatory-care-nursing" target=""> What Is Ambulatory Care Nursing? </a> <div class="we-mega-menu-submenu" data-element-type="we-mega-menu-submenu" data-submenu-width="" data-class="" style="width: px"> <div class="we-mega-menu-submenu-inner"> <div class="we-mega-menu-row" data-element-type="we-mega-menu-row" 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target=""> Value of the Ambulatory Care RN </a> </li> </ul> </div> </div> </div> </div> </li> <li class="we-mega-menu-li dropdown-menu we-mega-menu-group" data-level="1" data-element-type="we-mega-menu-li" description="" data-id="25609f4e-92c2-48d8-99d8-1478cc487880" data-submenu="1" hide-sub-when-collapse="" data-group="1" data-class="" data-icon="" data-caption="" data-alignsub="" data-target=""> <a href='#' data-drupal-link-system-path="<front>" class="we-megamenu-nolink"> Transition to Practice</a> <div class="we-mega-menu-submenu" data-element-type="we-mega-menu-submenu" data-submenu-width="" data-class="" style="width: px"> <div class="we-mega-menu-submenu-inner"> <div class="we-mega-menu-row" data-element-type="we-mega-menu-row" data-custom-row="0"> <div class="we-mega-menu-col span12" data-element-type="we-mega-menu-col" data-width="12" data-block="" data-blocktitle="0" data-hidewhencollapse="" data-class=""> <ul class="nav nav-tabs subul"> <li class="we-mega-menu-li" 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Transition Management (CCTM) Toolkit</span></h1><div class="views-field views-field-field-mast-summary"><div class="field-content"></div></div></div> </span></div></div> </span></div></div> </div> </div> </div> </div> </div> <main role="main"> <a id="main-content" tabindex="-1"></a> <div class="container"> <div class="row g-4"> <div class="order-2 order-lg-1 col-12 col-lg-3"> <div class="region region-sidebar-first"> <nav aria-labelledby="block-mainmenu-7-menu" id="block-mainmenu-7" class="block block-menu navigation menu--main"> <h5 id="block-mainmenu-7-menu"><a href="/practice-resources">Practice Resources</a></h5> <ul class="navbar-nav mr-auto"> <li class="nav-item dropdown nolink"> <span class="nav-item nav-link dropdown-toggle" role="xxbutton" data-xx-bs-toggle="dropdown" aria-expanded="false" title="Expand menu Ambulatory Care Nursing">Ambulatory Care Nursing</span> <ul class="dropdown-menu"> <li class="nav-item"> <a 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data-drupal-link-system-path="node/3040">Orientation and Competency Guide</a> </li> <li class="nav-item"> <a href="/practice-resources/transition-practice/nurse-residency-program" class="dropdown-item" data-drupal-link-system-path="node/3122">Nurse Residency Program</a> </li> <li class="nav-item"> <a href="https://www.aaacn.org/sites/default/files/documents/white-paper.pdf" class="dropdown-item">Ambulatory Care Registered Nurse Residency White Paper</a> </li> <li class="nav-item"> <a href="/practice-resources/transition-practice/preceptor-guide" class="dropdown-item" data-drupal-link-system-path="node/3048">Preceptor Guide</a> </li> <li class="nav-item"> <a href="/practice-resources/transition-practice/academicpractice-partnership-guidelines" class="dropdown-item" data-drupal-link-system-path="node/4309">Academic/Practice Partnership Guidelines</a> </li> </ul> </li> <li class="nav-item dropdown active nolink"> <span class="nav-item nav-link active dropdown-toggle" role="xxbutton" data-xx-bs-toggle="dropdown" aria-expanded="false" title="Expand menu Care Coordination & Transition Management (CCTM)">Care Coordination & Transition Management (CCTM)</span> <ul class="dropdown-menu"> <li class="nav-item"> <a href="/practice-resources/care-coordination-transition-management-cctm/cctm-scope-and-standards" class="dropdown-item" data-drupal-link-system-path="node/3101">CCTM Scope and Standards</a> </li> <li class="nav-item"> <a href="/practice-resources/care-coordination-transition-management-cctm/cctm-core-curriculum" class="dropdown-item" data-drupal-link-system-path="node/3353">CCTM Core Curriculum</a> </li> <li class="nav-item"> <a href="/practice-resources/care-coordination-transition-management-cctm/cctm-vs-case-management" class="dropdown-item" data-drupal-link-system-path="node/3099">CCTM vs. Case Management</a> </li> <li class="nav-item dropdown active"> <a href="/practice-resources/care-coordination-transition-management-cctm/care-coordination-and-transition" 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class="dropdown-item" data-drupal-link-system-path="node/3815">Telephone Triage and COVID-19</a> </li> </ul> </li> <li class="nav-item dropdown nolink"> <span class="nav-item nav-link dropdown-toggle" role="xxbutton" data-xx-bs-toggle="dropdown" aria-expanded="false" title="Expand menu Role of RN">Role of RN</span> <ul class="dropdown-menu"> <li class="nav-item"> <a href="/practice-resources/ambulatory-care/nursing-procedures" class="dropdown-item" data-drupal-link-system-path="node/3038">Nursing Procedures</a> </li> <li class="nav-item"> <a href="/practice-resources/role-rn/nurse-sensitive-indicators" class="dropdown-item" data-drupal-link-system-path="node/3037">Nurse-Sensitive Indicators</a> </li> <li class="nav-item"> <a href="/about/position-statements" class="dropdown-item" data-drupal-link-system-path="node/890">Position Statements</a> </li> </ul> </li> </ul> </nav> </div> </div> <div class="order-1 order-lg-2 col-12 col-lg-9"> <div class="region region-content"> <div id="block-aaacnv2-content" class="block block-system block-system-main-block"> <article role="article" about="/practice-resources/care-coordination-transition-management-cctm/care-coordination-and-transition" typeof="foaf:Document" class="node node--type-page node--view-mode-full"> <span property="dc:title" content="Care Coordination and Transition Management (CCTM) Toolkit" class="rdf-meta hidden"></span> <div class="node__content"> <div property="content:encoded" class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><h2 class="page-header">The Care Coordination and Transition Management Toolkit was designed with nurses like you in mind.</h2> <p><img alt="CCTM Toolkit" class="align-right" data-entity-type="file" data-entity-uuid="ed478dac-bcdf-4910-a7f1-d604a23d7510" id="" src="/sites/default/files/images-rte/cctm-toolkit-intro300w.png" title="" width="300" height="156" loading="lazy" />The CCTM toolkit was developed as an online interactive toolkit that AAACN members can use to enhance and advance practice and increase the effectiveness of the role of the RN in CCTM.</p> <p>It offers useful tools that support necessary materials to design, implement, or improve a CCTM program; including structure, process and outcome tools. CCTM resources are easy to find and easy to use!</p> <p>聽</p> <div class="callout-lightgreen"> <p><strong>To access the CCTM Toolkit, you must be logged in as a聽member of AAACN.</strong></p> <p>If you are a current聽member, simply <a href="https://my.aaacn.org/eweb/dynamicpage.aspx?site=AAACN&WebCode=ssoRedirect&destination=/practice-resources/care-coordination-transition-management-cctm/care-coordination-and-transition"><strong>log in</strong></a> for access.</p> <p>If you aren't聽a member, please <strong><a href="https://my.aaacn.org/eweb/DynamicPage.aspx?webcode=Membership&site=AAACN" target="_blank">join AAACN now</a></strong> to enjoy access to this toolkit and so many other benefits of membership.</p> </div> <p>聽</p> </div> </div> </article> </div> <div id="block-cctmtoolkitintro" class="block block-block-content block-block-content868b068e-0f36-498d-b342-ee0cda92e734"> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><div class="indented-blue"> <p><img align="right" src="/sites/default/files/images/SIGS/cctm/cctmLogo.png" style="max-width:20%;" /><br /> This toolkit from the American Academy of Ambulatory Care Nursing (AAACN) is designed to assist nurses and leaders working in the ambulatory care setting to develop and/or improve care coordination and transition management for patients.</p> <p>Contained within are all the necessary materials to design, implement, or improve a CCTM program; including structure, process, and outcome tools.</p> <p>Examples of some of these tools include: <strong>job descriptions</strong>, <strong>orientation programs</strong>, <strong>policies and procedures</strong>, and <strong>best practice outcome metrics</strong>.</p> <p>To maintain the ongoing relevance and value of this toolkit, we welcome your <a href="/practice-resources/care-coordination-transition-management-cctm/cctm-toolkit/suggest-tool">suggestions</a>.<br />  </p> </div> <div class="indented-div" style="margin-bottom: 1em;"> <h2>CCTM Toolkit Resources</h2> <p>Within the structure of the toolkit, tools are grouped into the following major categories:</p> <div class="collapsible-container closed" id="cctmtoolkit"> <h3 class="cctmtoolkit1"><a href="#cctmtoolkit1" style="color: #a64444 !important;">Structure</a></h3> <div class="pane"> <p>Refers to the conditions under which CCTM care is provided and includes the input elements and resources required to provide the care. Includes the providers of care, the tools and resources, and the physical and organizational setting in which they work; incorporates the human, physical, and financial resources needed to provide CCTM care.<br /> <br /> <strong>Examples: CCTM RN job descriptions including qualifications and responsibilities, orientation program, reporting structure.</strong></p> </div> <h3 class="cctmtoolkit2"><a href="#cctmtoolkit2" style="color: #cc8f36 !important;">Process</a></h3> <div class="pane"> <p>Refers to the content, actions, and procedures initiated by the CCTM RN and health care team in completing or facilitating the CCTM work; describes how the work is to be done.<br /> <br /> <strong>Examples: Policies, procedures, standards for CCTM RN in performing the role, processes for communication between team members.</strong></p> </div> <h3 class="cctmtoolkit3"><a href="#cctmtoolkit3" style="color: #1c6f1a !important;">Outcome</a></h3> <div class="pane"> <p>Refers to the desired states derived from the applied structure and processes; defines the desired result and how to measure.<br /> <br /> <strong>Examples: Identified outcomes and targets, measures/metrics, outcomes tracking, reporting and communication, data sources.</strong></p> </div> </div> <p><br /> To access the resources within the toolkit, you may choose below to either: <strong>Search the Toolkit</strong> by specific words or phrases; or, <strong>Browse the Toolkit</strong> by dimension of care to see the definition of that dimension and all the relevant toolkit resources, grouped by type and topic/source.</p> </div> </div> </div> </div> </div> </div> </div> </main> <footer class="mt-4 "> <div class="container"> <div class="region region-footer"> <div id="block-footer" class="block block-block-content block-block-content2c7ad540-06ab-45ae-8f8b-1aead7049969"> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><img alt="Home" class="footer-logo" src="/sites/default/files/aaacn-logo-trans_0.png" style="top: -2em;" /></p> <div class="contextual-region block block-block-content block-block-content2c7ad540-06ab-45ae-8f8b-1aead7049969" style="overflow:visible;"> <section class="block block-block aaacn-address col-lg-12 clearfix" id="block-block-14" style="padding-bottom: 1em;"> <p class="footer-row-1 text-align-center"><a href=" https://www.facebook.com/AAACN" rel="noopener" target="_blank"><img alt="" src="/sites/default/files/facebook-icon.png" style="filter: invert(1); border-width: 0px; border-style: solid;" /></a> <a href="https://twitter.com/AmbCareNursing" rel="noopener" target="_blank"><img alt="" src="/sites/default/files/X-icon.png" style="filter: invert(1);" /></a> <a href="https://www.linkedin.com/company/american-academy-of-ambulatory-care-nursing" rel="noopener" target="_blank"><img alt="" src="/sites/default/files/linkedin-icon.png" style="filter: invert(1);" /></a> <a href="https://www.instagram.com/ambcarenursing" rel="noopener" target="_blank"><img alt="" src="/sites/default/files/instagram-icon.png" style="filter: invert(1);" /></a></p> <p class="footer-row-2 text-align-center"><a href="/about/press-room">Press Room</a> | <a href="/about/media-coverage">Media Coverage</a> | <a href="/about/contact-aaacn">Contact</a> | <a href="/accreditation-statement">Accreditation Statement</a> | <a href="/about/privacypolicy">Privacy Policy</a> | <a href="/about/termsandconditionsofsale">Terms & Conditions of Sale</a></p> <p class="rtecenter">Copyright 漏2023, <a href="/">American Academy of Ambulatory Care Nursing (AAACN)</a>.<br /> No materials, including graphics, may be reused, modified, or reproduced without written permission.</p> </section> </div> </div> </div> </div> </div> </footer> </div> <script type="application/json" data-drupal-selector="drupal-settings-json">{"path":{"baseUrl":"\/","scriptPath":null,"pathPrefix":"","currentPath":"node\/2412","currentPathIsAdmin":false,"isFront":false,"currentLanguage":"en"},"pluralDelimiter":"\u0003","suppressDeprecationErrors":true,"google_analytics":{"account":"UA-37772294-1","trackOutbound":true,"trackMailto":true,"trackTel":true,"trackDownload":true,"trackDownloadExtensions":"7z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip","trackDomainMode":1},"data":{"extlink":{"extTarget":true,"extTargetNoOverride":false,"extNofollow":false,"extNoreferrer":false,"extFollowNoOverride":false,"extClass":"ext","extLabel":"(link is external)","extImgClass":false,"extSubdomains":true,"extExclude":"whatismybrowser\\.com","extInclude":"","extCssExclude":"nav, .btn","extCssExplicit":"","extAlert":false,"extAlertText":"This link will take you to an external web site. 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