The core text covers 13 dimensions, competencies, and activities. One chapter is dedicated to the transition from acute care to ambulatory care and the critical nature of hand-offs in ensuring patient safety and quality of care. Two chapters are devoted to technologies that provide decision support and information systems for all dimensions of care coordination and transition management: one focused on informatics and one focused on telehealth nursing practice. The text is evidence based and is organized to include definitions, learning outcomes and objectives, a table of knowledge, skills, and attitudes (KSAs), and nationally recognized core competencies for quality and safety education for nurses (QSEN), inter-professional collaborative practice, and public health nursing competencies. The text is written for nurses in all settings; from ambulatory care to hospitals, extended care facilities to student nurses.

Introduction -- Advocacy -- Education and engagement of patients and families -- Coaching and counseling of patients and families -- Patient-centered care planning -- Support for self-management -- Nursing process (proxy for monitoring and evaluation) -- Teamwork and collaboration -- Cross-setting communications and care transitions -- Population health management -- Care coordination and transition management (CCTM) between acute care and ambulatory care -- Informatics nursing practice -- Telehealth nursing practice.