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AONL and the American Academy of Ambulatory Care Nursing collaborated to outline how nurse leaders in inpatient and post-acute/outpatient settings should approach their roles to enhance development of care coordination and transition management across the continuum of care.

Beyond the hospital and physician’s offices, patients are cared for in specialized settings based on their specific needs. Most modern hospitals and health care systems include a number of services or programs that fall into the category of post-acute care, including institutional-based programs such as inpatient rehabilitation facilities (IRFs), skilled-nursing facilities (SNFs) and long-term care hospitals, as well as home and community-based services, such as home health and hospice care.