Outline:
Section 1: Introduction A. About This Course B. Learning Objectives Section 2: PCMH Overview A. Model of Care B. Concepts C. Review D. Summary Section 3: Care Management and Support A. Introduction B. Care Manager C. Competency A D. Core Criterion 1: Identifying Patients E. Core Criterion 2: Monitor Total Patients in Care Management F. Elective Criterion for Competency A G. Competency B H. Core Criterion 4: Development of Care Plan I. Core Criterion 5: Patient Receives Care Plan J. Elective Criteria for Competency B K. Care Management Opportunities L. Care Management and Information Technology M. Review N. Summary Section 4: Care Coordination and Care Transitions A. Introduction B. Competency A C. Core Criterion 1: Laboratory and Imaging Results D. Lab Audit E. Elective Criteria for Competency A F. Competency B G. Core Criterion 4: Referrals H. Elective Criteria for Competency B I. Competency C J. Core Criterion 14: Identify Unplanned Admissions and Emergency Department Visits K. Core Criterion 15: Shares Information with Hospitals and Emergency Departments L. Core Criterion 16: Follow-up After Admissions or Emergency Department Visits M. Elective Criteria for Competency C N. Review O. Summary Section 5: Conclusion A. Summary B. Course Contributors C. Resources D. References E. Congratulations! F. Exam

Elizabeth Kellerman MSN, RN started in nursing in 2007 after graduating from Samuel Merritt University in Oakland, California. While working in a critical care unit at Sutter Mills-Peninsula Hospital she earned her CCRN and TNCC. Her experience and knowledge led her to nursing education where she taught at a community college while working to receive her Master's in Nurse Education at Western Carolina University. As a nursing instructor, she spent time in many types of care settings including medical-surgical inpatient and community living centers. Her passion for education and training has most recently led her to a position as subject matter expert and content writer for Relias. Disclosure: Elizabeth Kellerman, MSN, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.