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 worked as a critical care nurse in an Intensive Care Unit of a community hospital and that experience provided significant training in caring for older adults. Her experience and knowledge led her to nursing education where she taught at a community college as she received 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. She is currently developing her medical writing skills through the University of California San Diego's medical writing program. Disclosure: Elizabeth Kellerman, MSN, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.