Ambulatory Care Care Coordination and Transitions Flashcards
7 cards from real Ambulatory Care Test practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Ambulatory Care Care Coordination and Transitions flashcards as text
A patient with heart failure is being discharged from the hospital. Which intervention is MOST effective in reducing 30-day readmission rates?
Answer: Scheduling a follow-up appointment within 7 days of discharge
Follow-up within 7 days of discharge is strongly associated with reduced 30-day readmission rates for heart failure patients.
Which tool is most commonly used to assess a patient's risk for hospital readmission in the ambulatory setting?
Answer: LACE index
The LACE index (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) is a validated tool for predicting readmission risk.
A care coordinator notices that a patient's specialist notes are not reaching the primary care provider. Which strategy BEST addresses this care gap?
Answer: Implementing a shared electronic health record or care summary portal
A shared EHR or care summary portal ensures that all providers have timely access to the same clinical information.
Under the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for excess readmissions for which condition?
Answer: Chronic obstructive pulmonary disease (COPD)
COPD is one of the CMS-designated conditions (along with heart failure, pneumonia, and others) subject to HRRP penalties.
A patient with diabetes does not fill a new insulin prescription after discharge. Which barrier to medication adherence does this MOST likely represent?
Answer: Cost-related non-adherence
Cost-related non-adherence is a leading reason patients fail to fill prescriptions, especially for expensive medications like insulin.
Which team member is PRIMARILY responsible for conducting medication reconciliation during a care transition from hospital to home?
Answer: Pharmacist
Pharmacists are the primary professionals trained to perform comprehensive medication reconciliation and identify discrepancies during transitions of care.
A care coordinator is using the BOOST (Better Outcomes by Optimizing Safe Transitions) toolkit. This toolkit is PRIMARILY designed to:
Answer: Improve care transitions and reduce readmissions
The BOOST toolkit provides evidence-based resources and checklists specifically designed to improve hospital-to-home transitions and reduce readmissions.