Transitional Care Management and Care Coordination

Jointly Provided by Postgraduate Institute for Medicine and National Readmission Collaborative, Inc.
Release date: 5/13/19, Expiration date: 5/13/21
(Expiration date for NAB/NCERS: 5/12/2020) (Expiration date for CCMC PACE: 04/18/2020)
Estimated time to complete activity: 1 hour and 30 minutes
Mechanism for the learner to contact PIM – i.e., hyperlink to PIM’s website (
$149 Regular
This activity is intended for Physicians, Physician Assistants, Nurse Practitioners, Registered Nurses, Healthcare Executives, Social Workers, Case Managers, and Resident Care Facility/Nursing Home Administrators engaged in Care Transitions and Readmission Prevention of patients.
After completing this activity, the participant should be better able to:

  • Define the reasons that avoidable hospital readmissions negatively impact the patient, hospital and Medicare program
  • The learner will employ critical skills and tactics that lead to reduced hospital readmission rates
  • Learners will be able to identify key risk factors that lead to increased readmissions
  • The learner will be able to analyze a patient’s history and differentiate each patient’s needs and risk factors that lead to high rates of readmission
  • The learner will develop a through patient care plan & assess the outcome of that plan if an admission within 30 days of discharge is avoided
Josh Luke, Ph.D, FACHE
Founder & CEO
National Readmission Prevention Collaborative
Adjunct Faculty, University of Southern California, Sol Price School of Public Policy
Doctorate of Education, University of Nevada; Educational Leadership
Long time Hospital CEO & Nursing Home Administrator (and preceptor)

Josh Luke, Ph.D, FACHE has no conflicts to report
The PIM planners and managers have nothing to disclose

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and National Readmission Prevention Collaborative, Inc. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
The Postgraduate Institute for Medicine designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Postgraduate Institute for Medicine designates this continuing education activity for 1.5 contact hour(s) (0.15 CEUs) of the Accreditation Council for Pharmacy Education.
(Universal Activity Number – JA4008162-9999-19-707-H04-P)
Type of Activity: Application
This educational activity requires access to a computer, phone or pad with Microsoft Word and Power Point capabilities, as well as basic internet access and a functioning browser that allows video streaming.
The National Readmission Prevention Collaborative
( is owned by NRPC, Inc. a California not for profit entity. The NRPC privacy policy is available on our site and explains the practices of NRPC, Inc. regarding collection, use and disclosure of personally identifying information that you may provide through the NRPC site and other information that we collect passively when you use the NRPC Site.
The maximum number of hours awarded for this Continuing Nursing Education activity is 1.5 contact hours.
This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit to Certified Case Managers (CCMs).
This program has been approved for Continuing Education for 1.75 total participant hours by NAB/NCERS—Approval #20200512-1.75-A54751-DL
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
During the period April 2019 through April 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the evaluation on . On the navigation menu, click on “Find Post- test/Evaluation by Course” and search by course ID. The course ID will provided to you once you successfully complete the post-test with a score of 75% or better.

For Pharmacists: Upon successfully completing the post-test with a score of 75% or better and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service.