Advanced Care Coordination Series: Settings

In this series the role of the Registered Nurse in advancing care coordination across patient care settings is examined.  Learning sessions provide an overview of acute care transitions, primary care and long term services and supports including home health and hospice.  Health policy and interventions that have been shown to be effective in improving care coordination for patients across care settings are described. Patient centered care as it relates to coordination roles for RNs are emphasized.  Current evidence and resources to support care coordination practice are recommended.

Who Should Enroll
  • All RNs who want to know more about care coordination across different settings.
  • Registered Nurses new or experienced in RN care management, care transitions or care coordination who are seeking a better understanding of new and emerging care coordination roles and expectations.
  • RNs and Advanced Practice RNs who are working in Accountable Care Organizations, Patient Centered Medical Homes or Long Term Services and Supports.
CE Accreditation Statement
  • This nursing continuing professional development activity was approved by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. WNA CEAP Approval Number: WICEAP-0183

Continuing Education hours will be awarded only for those hours completed. Up to 27 hours may be completed through this series.

RN Case Managers who are certified by CCMC, the Commission for Case Manager Certification, are required to submit 80 hours of continuing Education every 5 years.  All Courses offered by the National RN Case Manager Training Center are pre-approved by the American Nurses Credentialing Center and accepted for renewal by CCMC. CCMC has posted clear downloadable instructions for submitting renewal CE. There is a nominal charge of $15.00 per submission for CE that has not been pre-approved by CCMC. See CCMC website renewal section for details.  https://ccmcertification.org/stay-certified/renewal/renewal-guide

National RNCM Continuing Education courses are ANCC approved for use in all U.S. States and territories.

Download CE Accreditation Statement

Learning Option: Online

Online education is an effective course delivery strategy for learners who desire or need the convenience and flexibility to learn at their own pace and in their own environment. Online learning requires participants to be self-directed in completing program content. Comfort with technology and strong time management skills are a must. In this learning format, faculty utilize the Training Center’s eLearning platform to deliver lectures, course content, materials and practice resources and tools. Online Training is also available to organizations upon request. 

How This Series Works
  • Select from the list of sessions to meet your own individual learning needs.
  • Register and receive course confirmation via email and begin.
  • Complete content working at your own pace, on your own schedule coming in and out of the online classroom as your time allows.
  • 30 days to complete each Session.
  • Interact with faculty as needed electronically.
  • Print off/download your CE award upon completion of the content.

Sessions / Topics in this Series

Care Coordination for Different Settings

Acute Care Transitions (3 CE)

This session discusses the care coordination issues, implementation and gaps in Acute Care settings.  Nurses’ roles in facilitating effective care transitions will be described along with best practices for effective patient discharge.  Mary Naylor’s ‘Transitional Care Model’ will be examined, including a description of the role of the RN and NP in acute care transitions. The Center for Medicare and Medicaid Services (CMS) payment rules specific to transitional care will be explained.

Tuition: $99

Primary Care and Patient Centered Medical Homes (3 CE)

Transformation of the U.S. Healthcare system includes a shift away from acute care with a focus on primary care.  This will require RNs to have a better understanding of primary care including care coordination issues, implementations and gaps.  Nurse Care Coordination models will be described including the essential functions, roles and practice of nurses embedded in Patient Centered Medical Homes.  National Committee for Quality Assurance (NCQA) criteria for medical home certification including requirements for care coordination will be explained.

Tuition: $99

Long Term Services and Supports (3 CE)

Effective care coordination requires RNs to strengthen their understanding of Long Term Care Services and Supports.  In this session Long Term Care systems are reviewed and care coordination issues, implementation and gaps discussed.  Housing progression for changing needs in aging is described.  Evidence related to emerging nurse practice models that move beyond traditional options will be examined.  Local and national polices that support or hinder new LTSS possibilities are reviewed including current and emerging payment models.

Tuition: $99