Ambulatory Care Test Ambulatory Care Care Coordination and Transitions 2 — Questions and Answers
Question 1: A patient with heart failure is being discharged from the hospital. Which intervention is MOST effective in reducing 30-day readmission rates?
- Scheduling a follow-up appointment within 7 days of discharge (Correct answer)
- Providing a written medication list at discharge
- Referring the patient to a cardiologist within 30 days
- Ordering a home health aide for personal care
Correct 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.
Question 2: Which tool is most commonly used to assess a patient's risk for hospital readmission in the ambulatory setting?
- CAGE questionnaire
- LACE index (Correct answer)
- PHQ-9 scale
- Morse Fall Scale
Correct answer: LACE index
The LACE index (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) is a validated tool for predicting readmission risk.
Question 3: A care coordinator notices that a patient's specialist notes are not reaching the primary care provider. Which strategy BEST addresses this care gap?
- Advising the patient to hand-carry paper records to each visit
- Implementing a shared electronic health record or care summary portal (Correct answer)
- Scheduling all specialist visits on the same day
- Limiting specialist referrals to reduce documentation burden
Correct 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.
Question 4: Under the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for excess readmissions for which condition?
- Asthma
- Chronic obstructive pulmonary disease (COPD) (Correct answer)
- Hypertension
- Diabetes mellitus
Correct 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.
Question 5: A patient with diabetes does not fill a new insulin prescription after discharge. Which barrier to medication adherence does this MOST likely represent?
- Therapeutic duplication
- Cost-related non-adherence (Correct answer)
- Polypharmacy
- Drug-drug interaction
Correct answer: Cost-related non-adherence
Cost-related non-adherence is a leading reason patients fail to fill prescriptions, especially for expensive medications like insulin.
Question 6: Which team member is PRIMARILY responsible for conducting medication reconciliation during a care transition from hospital to home?
- Social worker
- Pharmacist (Correct answer)
- Physical therapist
- Nutritionist
Correct answer: Pharmacist
Pharmacists are the primary professionals trained to perform comprehensive medication reconciliation and identify discrepancies during transitions of care.
Question 7: A care coordinator is using the BOOST (Better Outcomes by Optimizing Safe Transitions) toolkit. This toolkit is PRIMARILY designed to:
- Screen patients for depression before discharge
- Improve care transitions and reduce readmissions (Correct answer)
- Standardize wound care protocols in outpatient settings
- Train nurses in motivational interviewing
Correct 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.
Ambulatory Care Test Ambulatory Care Care Coordination and Transitions 2
A patient with heart failure is being discharged from the hospital.
Which intervention is MOST effective in reducing 30-day readmission rates?