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Care Coordination and Transition Management


The Care Coordination and Transition Management (CCTM) online course and text define the integral role of the RN in the interprofessional team and applies to nurses in all setting from ambulatory care to hospitals.

The content was originally developed by the American Academy of Ambulatory Care Nursing (AAACN). NPCS collaborated with our KP Regional Partners (special thanks to Anja Peerson from the NW Region), NWFPD/BHMT, AAACN, S4Netquest, and HealthStream to enhance the education delivery and to significantly cut the price for all modules to a total of $30.00. This $30 price is only available for KP employees. Our collaboration has resulted in a format and price that promotes accessibility to our Kaiser Permanente nursing community.

These resources are a “must have” for any registered nurse who is responsible for coordinating care and managing transitions. They are designed to improve patient outcomes, decrease health care costs, and promote sustainable system change.

  1. Overview/ Introduction
    Care Coordination and Transition Management -Identifies key components of the CCTM Core Curriculum.
  2. Advocacy
    Integrates professional standards of nursing related to advocacy into the RN Care Coordination and Transition Management (RN-CCTM) role.
  3. Education and Engagement of Patients and Families
    Identifies methods to assess patient and family learning needs, create learning opportunities, and promote an open learning environment in which the learner works toward self-management and optimal health.
  4. Coaching and Counseling of Patients and Families
    Utilizes the existing strengths of the care team to create innovative ways to engage patients and families in the care plan.
  5. Patient-Centered Care Planning
    Demonstrates the ability to develop, implement, and provide ongoing management of a comprehensive plan of care – based upon the individual patient's values, preferences, and needs – in partnership with the primary care provider and larger interdisciplinary care team.
  6. Support for Self-Management
    Demonstrates the primary components of self-management support, including the importance of a comprehensive needs assessment, common strategies for collaborative goal setting, and concepts important to self-management.
  7. Nursing Process
    Proxy for Monitoring and Evaluation- Demonstrates required steps in the nursing process when performing in the role of the RN in CCTM.
  8. Teamwork and collaboration
    Application of effective teamwork and collaboration skills into the RN Care Coordination and Transition Management (RN-CCTM) role.
  9. Cross setting Communications and Care Transitions Demonstrates the knowledge, skills, and attitudes required for Cross-Setting Communication and Transitions in Care.
  10. Population Health Management
    Integrates the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role.
  11. CCTM Between Acute Care and Ambulatory Care
    Shows the impact of a mutually developed, implemented, and continuously evaluated transition of care plan has on quality of care, patient satisfaction, patient outcomes, and financial impact, and understand the importance of integrating evidence-based practice guidelines into a transition of care plan.
  12. Informatics Nursing Practice
    Demonstrate the elements of competency in informatics nursing practice that are required for the registered nurse (RN) in Care Coordination and Transition Management (CCTM) role. Specific learning outcomes and objectives have been identified for each competency.
  13. Telehealth Nursing Practice
    Demonstrates the elements of competency in professional telehealth nursing practice that are required for the RN in CCTM role.

The CCTM online course and core test will help nurses solve the puzzle of fragmented patient care. It is an evidence-based, patient-care program designed to:

  • Improve patient outcomes
  • Enhance access to quality care
  • Decrease hospital readmissions
  • 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 (PCMHs) and Accountable Care Organizations (ACOs)
  • Improve the individual patient’s experience of care

The course includes audio presentation, interactive activities, knowledge checks, and a PDF version of the corresponding core text chapter. Nurses will read the chapters prior to viewing the audio presentation.


  • User licenses fee for all 13 modules is $30.
  • The modules can be accessed via HealthStream and HealthStream Express.
  • Managers will coordinate with the purchasing of user licenses for region, unit, or department and HealthStream administrators will assign the course.
  • Individual user licenses will not be sold. To place an order, please send an email with all requirements from order checklist to CCTM@KPNursing.org.


  • Name and contact info of requesting manager
  • Name and address of facility
  • Name and contact information of HealthStream Administrator for your department, facility, or region.
  • GL string for billing
  • # of user licenses requesting (no individual licenses will be invoiced)



For questions and technical support, please send an email to CCTM@KPNursing.org.