Care Transitions & Discharge Planning Flashcards

Which legislation mandates that hospitals share discharge planning information with patients in a timely manner and offer them a choice of post-acute care providers?

Answer: Improving Medicare Post-Acute Care Transformation (IMPACT) Act

The IMPACT Act requires standardized data submission and mandates that hospitals involve patients in choosing their post-acute care setting and provide timely discharge planning information.

A patient with limited English proficiency is being discharged. The CNL's PRIORITY action regarding discharge education is to:

Answer: Use a qualified medical interpreter to provide and verify discharge instructions

A qualified medical interpreter ensures accurate communication and protects patient rights; using family members as interpreters can lead to errors and violates best practice standards.

A CNL is designing a care transition program for high-risk elderly patients. Which post-discharge contact timeline is supported by EVIDENCE as optimal for preventing early readmission?

Answer: Phone or in-person contact within 24-72 hours of discharge

Evidence supports early post-discharge contact within 24-72 hours to identify and address problems — such as medication confusion or worsening symptoms — before they lead to readmission.

In the CNL competency framework, 'lateral integration of care' during transitions refers to:

Answer: Coordinating care across multiple providers and settings simultaneously for a specific patient

Lateral integration means the CNL coordinates care horizontally across providers, disciplines, and settings at the same time to ensure seamless transitions for a cohort of patients.

When performing a comprehensive discharge needs assessment, which domain is MOST commonly overlooked but critical for safe transitions?

Answer: Social support and home environment safety (e.g., caregiver availability, fall hazards)

Social support and home environment safety — including caregiver availability and physical hazards — are frequently underassessed yet are among the strongest predictors of post-discharge complications.

A CNL is reviewing data showing that 40% of post-discharge patients do not fill their prescriptions within 72 hours. The BEST system-level intervention is:

Answer: Implementing a bedside medication delivery program before discharge (meds to beds)

A 'meds to beds' program delivers discharge medications to the patient's bedside before they leave, directly eliminating the barrier of accessing a pharmacy and ensuring immediate adherence.

Which statement BEST reflects the CNL's role in supporting patients during care transitions as defined by the American Association of Colleges of Nursing (AACN)?

Answer: The CNL serves as the coordinator of care at the point of care, overseeing the microsystem and facilitating safe transitions

According to AACN, the CNL coordinates care at the microsystem level, which includes actively facilitating safe and effective care transitions for their patient cohort.