Care Transitions & Discharge Planning Flashcards

Which of the following is the PRIMARY goal of a structured discharge planning process in the CNL role?

Answer: Ensuring continuity of care and preventing avoidable readmissions

The primary goal of discharge planning is to ensure continuity of care and prevent avoidable readmissions by coordinating resources and follow-up services.

The CNL notices a patient has multiple chronic conditions, low health literacy, and limited social support. Which discharge strategy is MOST appropriate?

Answer: A teach-back session with caregivers plus a follow-up call within 48 hours

Teach-back with caregivers and a post-discharge follow-up call addresses low health literacy and social isolation, reducing readmission risk.

Which model specifically focuses on reducing rehospitalizations through nurse-led home visits and phone follow-up after discharge?

Answer: Care Transitions Intervention (CTI)

The Care Transitions Intervention (CTI), developed by Eric Coleman, uses nurse-led home visits and follow-up calls to empower patients and reduce rehospitalizations.

A patient being discharged after a hip replacement asks about weight-bearing restrictions. The CNL's BEST response is to:

Answer: Provide written instructions and use teach-back to confirm understanding

Using teach-back to confirm understanding of written instructions ensures the patient truly comprehends restrictions, reducing the risk of injury or readmission.

Which federal program penalizes hospitals financially for excess readmissions within 30 days for certain conditions?

Answer: Hospital Readmissions Reduction Program (HRRP)

The Hospital Readmissions Reduction Program (HRRP) reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for qualifying conditions.

Which patient factor is the STRONGEST independent predictor of 30-day hospital readmission?

Answer: History of prior hospitalizations in the past 6 months

A history of prior hospitalizations is consistently identified as the strongest predictor of 30-day readmission across disease categories.

A CNL is coordinating discharge for a patient going to a skilled nursing facility (SNF). Which action is MOST critical before transfer?

Answer: Sending a complete, reconciled medication list and care summary to the receiving facility

Transmitting a complete, reconciled medication list and care summary ensures the receiving SNF has the information needed to safely continue care and prevent errors.