Care Transitions & Discharge Planning Flashcards

During medication reconciliation at discharge, the CNL discovers a patient was prescribed two anticoagulants — one new and one pre-admission. The FIRST action should be:

Answer: Clarify the discrepancy with the prescribing physician before discharge

Medication discrepancies must be clarified with the prescribing physician before discharge to prevent potentially life-threatening duplication errors.

The BOOST (Better Outcomes by Optimizing Safe Transitions) tool is primarily used to:

Answer: Identify patients at high risk for readmission so targeted interventions can be applied

Project BOOST uses validated risk assessment tools to identify patients at high risk for 30-day readmission so that focused discharge interventions can be applied.

Which element is considered a CORE component of an effective transition of care record (transition of care summary)?

Answer: Reconciled medication list, active problem list, and pending test results

A complete transition of care summary must include a reconciled medication list, active problems, and pending results to ensure safe handoffs between providers.

A CNL is implementing a bundle to reduce heart failure readmissions. Which intervention has the HIGHEST evidence for reducing 30-day readmissions in this population?

Answer: Patient self-monitoring of daily weight with a clear action plan for weight gain

Daily weight self-monitoring with a clear action plan (when to call, when to go to ER) is among the highest-evidence interventions for reducing heart failure readmissions.

When using the 'teach-back' method during discharge education, the nurse's CORRECT approach is to ask:

Answer: 'Can you explain to me in your own words how to take this medication?'

Teach-back requires the patient to demonstrate understanding by explaining or demonstrating in their own words, rather than answering a yes/no comprehension question.

Which team member is MOST important to include in discharge planning for a patient with complex social needs such as homelessness or food insecurity?

Answer: The social worker or case manager

Social workers and case managers have expertise in connecting patients with community resources to address social determinants of health that affect post-discharge outcomes.

A CNL is evaluating a newly implemented discharge planning protocol. Which metric BEST measures the protocol's effectiveness at improving care transitions?

Answer: 30-day all-cause readmission rate

The 30-day all-cause readmission rate directly measures whether the discharge planning protocol is achieving the outcome of keeping patients safely at home after discharge.