This document is an evolution of the American Academy of Ambulatory Care Nursing’s (AAACN) body of work and a major step forward for nurses in care coordination and transition management (CCTM). It is the first statement of the scope and standards of practice for RNs engaged in CCTM. CCTM roles focus on communicating and partnering with other professional health care colleagues across diverse health care settings. These settings include ambulatory care, acute care, post-acute care, long-term care facilities, and diverse community settings. This document may be used as a tool to advance professional CCTM nursing practice, patient and population health, and the performance outcomes of health care institutions.
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