Managing Care Transitions

Reducing readmissions - major focus of the Affordable Care Act!

Through healthcare reform and new initiatives, the federal government aspires to save $26 billion dollars in the coming years by leaning on hospitals to lower their preventable readmission rates.  Inadequate management of care transitions is responsible for billions of dollars in wasteful spending due to avoidable complications and unnecessary hospital readmissions.  With impending cuts to Medicare spending, hospitals must be motivated to develop solutions for reducing readmission rates.   

The goal of this 4-part online series is to describe nursing initiatives that are effective in reducing readmissions:

  1. Care coordination
  2. Increasing patient adherence
  3. Teach Back: Ensuring patient understanding
  4. Multidisciplinary collaboration via rounds

Accreditation Statement:  The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Statement of Contact Hours:  This 1.5 contact hour educational activity is provided by The Institute for Johns Hopkins Nursing.This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit to Certified Case Manager (CCMC). After completion of the activity, post-test and evaluation a certificate will be issued.
Conflict of Interest:  It is the policy of The Institute for Johns Hopkins Nursing to require our continuing nursing education program faculty and planning committee members to disclose any financial relationships with companies providing program funding or manufacturers of any commercial products discussed in the program.  The planning committee and program faculty report that they do not have financial relationships with manufacturers of any commercial products they discuss in the program.
Commercial Support:  This educational activity has not received any form of commercial support. The interventions noted as part of the care coordination initiative were partially funded by a CMMI grant

Non-Endorsement of Products:  The Institute for Johns Hopkins Nursing and the American Nurses Credentialing Center does not endorse the use of any commercial products discussed or displayed in conjunction with this educational activity.

Target Audience

RNs, particularly case managers, care managers, transitional nurses, patient navigators, nurse managers, and advanced practice nurses.

(Johns Hopkins Health System staff make take this course free of charge.  To access the coupon you need to register, go to the JHH Nursing Intranet. If you are with the JHHS and aren't able to access the intranet, email us.)

Learning Objectives

At the close of this activity, participants will be able to:

Care Coordination:

  1. Describe the issue of hospital readmissions in the USA.
  2. Describe initiatives to improve care and decrease readmissions through care coordination.

Adherence for Health:

  1. Define the concept of adherence.
  2. Discuss the prevalence of non-adherence.
  3. Describe barriers to adherence.
  4. Discuss strategies to promote adherence.

Teach Back: Ensuring Patient Understanding

  1. Describe the impact of health literacy on patient care.
  2. Describe the Teach Back process.
  3. Identify Teach Back techniques.

Multidisciplinary Collaboration via Rounds:

  1. Describe the structure and content of multidisciplinary rounds.
  2. Describe members of the care team.
  3. Discuss the goals of multidisciplinary rounds.
Additional information
Contact email: 
Course summary
Available credit: 
  • 1.50 ANCC
Registration opens: 
Registration closes: 

Nancy Sullivan, RN, DNP

Care Coordination Initiative
Johns Hopkins Health System

Available Credit

  • 1.50 ANCC


Please login or register to take this course.