Patient Centered Medical Home: Care Management, Coordination, and Transition

Patient Centered Medical Home: Care Management, Coordination, and Transition  

The goal of this course is to provide learners with practical information on how they can meet the 2017 National Committee for Quality Assurance (NCQA) standards. In this module, you will learn about the 4th and 5th concepts of the Patient-Centered Medical Home (PCMH) model called Care Management and Support and Care Coordination and Care Transitions. To demonstrate the concept of Care Management and Support your practice will need to demonstrate competency in 2 areas. To demonstrate Care Coordination and Care Transitions, practices will need to demonstrate competency in 3 areas. Further, this module will go into detail about the core criteria required to satisfy the competencies for each concept. It will not review elective criteria.


Hours: 1.75


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-CH-0-PCMH4
Hours: 1.75
Type: Online Course
Content Expiration Date: 8/31/2023
Learning Objectives:
Identify the concepts of Care Management and Support, and Care Coordination and Care Transitions.
Describe core criteria associated with concepts in this course.
Give examples of activities that satisfy the core criteria for the concepts in this module.

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

Instructor: Elizabeth Kellerman, MSN, RN
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.
Target Audience:
The target audience for this course is: Entry, Intermediate level General Staff; in the following settings: Acute Care Facility.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form ( or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.