Developing ambulatory care registered nurse competencies for care coordination and transition management.

The need for care coordination and management of transitions between Patient-Centered Medical Home providers, outpatient and community settings, including the Accountable Care Organization is often overlooked, episodic, and accountability for coordinating care and managing transitions between providers and services is lacking. Recognizing the potential of the RN to contribute to enhanced quality, cost effectiveness, and access to care in ambulatory settings, the Board of Directors of the American Academy of Ambulatory Care Nursing (AAACN) created a care coordination competencies action plan with three phases to delineate RN competencies and develop an education program for care coordination and transition management in ambulatory care. The first Expert Panel completed a comprehensive, interdisciplinary literature review and analysis focused on care coordination and transition management. The second Expert Panel--representing nu rsing, medicine, and pharmacy--defined the dimensions, identified core competencies, and described the activities linked with each competency for care coordination and transition management in ambulatory settings. The third Expert Panel reviewed, confirmed, and created a table of dimensions, activities, and competencies (including knowledge, skills, attitudes) for ambulatory care RN care coordination and transition management.