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 schizophrenia is being transitioned from inpatient psychiatric care to an outpatient community mental health center. The MOST important care coordination priority is:
Answer: Ensuring the patient has a confirmed outpatient appointment before discharge
Confirming an outpatient appointment before psychiatric discharge is the highest priority to prevent care gaps that increase relapse and readmission risk.
The Agency for Healthcare Research and Quality (AHRQ) IDEAL Discharge Planning model includes which key component?
Answer: Educating patients and families using plain language and teach-back
The IDEAL model emphasizes patient and family education using plain language and teach-back to ensure comprehension before discharge.
A care coordinator identifies that a recently discharged patient has not attended any of three scheduled follow-up appointments. The BEST next step is:
Answer: Conduct outreach to identify and address specific barriers to attendance
Identifying and addressing the root cause of missed appointments (transportation, cost, work schedule) is the most effective approach before closing or reducing care.
Which of the following BEST describes the role of a Patient-Centered Medical Home (PCMH) in care transitions?
Answer: Serving as the coordinating hub that tracks patients across all care settings
The PCMH model designates the primary care practice as the coordinating hub responsible for tracking and managing the patient across all transitions and care settings.
A nurse practitioner is using motivational interviewing (MI) during a transition of care visit. Which statement BEST reflects an MI technique?
Answer: 'What concerns do you have about starting this new medication?'
Asking open-ended questions to explore the patient's concerns is a core MI technique that builds autonomy and engagement rather than prescribing behavior.
Which metric is commonly used to evaluate the effectiveness of a care transitions program?
Answer: 30-day all-cause hospital readmission rate
The 30-day all-cause readmission rate is the standard outcome metric used to evaluate how well care transitions programs prevent unnecessary hospitalizations.
A transition of care pharmacist reviews a patient's discharge medication list and finds the patient is prescribed both warfarin and a new NSAID. This represents:
Answer: A clinically significant drug-drug interaction requiring intervention
Concurrent use of warfarin and NSAIDs significantly increases bleeding risk and requires immediate intervention or provider notification.