CNL Care Transitions & Discharge Planning 1 — Questions and Answers
Question 1: Which of the following is the PRIMARY goal of a structured discharge planning process in the CNL role?
- Reducing hospital length of stay to lower costs
- Ensuring continuity of care and preventing avoidable readmissions (Correct answer)
- Completing required documentation before the patient leaves
- Notifying insurance providers of the discharge date
Correct 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.
Question 2: The CNL notices a patient has multiple chronic conditions, low health literacy, and limited social support. Which discharge strategy is MOST appropriate?
- Standard written discharge instructions given at bedside
- A teach-back session with caregivers plus a follow-up call within 48 hours (Correct answer)
- Referral to the social worker only
- Early discharge to reduce infection exposure
Correct 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.
Question 3: Which model specifically focuses on reducing rehospitalizations through nurse-led home visits and phone follow-up after discharge?
- SBAR Model
- Care Transitions Intervention (CTI) (Correct answer)
- Donabedian Model
- Lean Six Sigma
Correct 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.
Question 4: A patient being discharged after a hip replacement asks about weight-bearing restrictions. The CNL's BEST response is to:
- Refer all questions to the orthopedic surgeon's office
- Provide written instructions and use teach-back to confirm understanding (Correct answer)
- Tell the patient to look up the information online
- Document that education was provided and move on
Correct 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.
Question 5: Which federal program penalizes hospitals financially for excess readmissions within 30 days for certain conditions?
- Medicare Advantage
- Hospital Readmissions Reduction Program (HRRP) (Correct answer)
- Meaningful Use Program
- Value-Based Insurance Design
Correct 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.
Question 6: Which patient factor is the STRONGEST independent predictor of 30-day hospital readmission?
- Patient age over 65
- History of prior hospitalizations in the past 6 months (Correct answer)
- Female gender
- Urban versus rural residence
Correct 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.
Question 7: A CNL is coordinating discharge for a patient going to a skilled nursing facility (SNF). Which action is MOST critical before transfer?
- Calling the SNF dietary department about food preferences
- Sending a complete, reconciled medication list and care summary to the receiving facility (Correct answer)
- Informing the patient's employer about the discharge
- Removing the IV access before transport
Correct 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.
CNL Care Transitions & Discharge Planning 1
Which of the following is the PRIMARY goal of a structured discharge planning process in the CNL role?