Care Transition Processes Flashcards

The Care Transitions Intervention (CTI) developed by Eric Coleman focuses primarily on which four pillars?

Answer: Medication self-management, patient-centered record, follow-up, red flag awareness

Coleman's CTI model centers on medication self-management, a patient-centered health record, timely follow-up, and knowledge of red flags indicating deterioration.

A patient is discharged from the hospital but readmitted within 30 days for the same condition. Under CMS value-based purchasing, this most directly affects which hospital metric?

Answer: Hospital Readmissions Reduction Program (HRRP) penalty

The HRRP penalizes hospitals with excess readmissions within 30 days for specific conditions by reducing Medicare payments.

Which handoff tool uses a structured format with Situation, Background, Assessment, and Recommendation components during care transitions?

Answer: SBAR

SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool widely used during clinical handoffs to ensure critical information is conveyed.

A quality team wants to reduce post-discharge medication errors. Which intervention is MOST effective as a first step?

Answer: Conducting medication reconciliation at all transition points

Medication reconciliation at every transition point is the foundational intervention for catching discrepancies that cause post-discharge medication errors.

The Transitional Care Model (TCM) developed by Mary Naylor is best characterized by which approach?

Answer: Advanced practice nurses providing in-home follow-up after hospital discharge

Naylor's TCM uses advanced practice nurses who follow high-risk patients from hospital to home, providing comprehensive post-discharge support.

When assessing the quality of care transitions, which metric is considered the most direct indicator of transition failure?

Answer: Unplanned 30-day hospital readmission rate

Unplanned 30-day readmissions are widely accepted as the most direct measurable indicator that a care transition was inadequate or failed.

A care transitions coordinator notices that patients transferred from ICU to medical-surgical units frequently experience lapses in antibiotic therapy. Which process improvement should be prioritized?

Answer: Implementing a structured intra-hospital handoff checklist that includes active medication orders

A structured handoff checklist that explicitly includes active medication orders ensures continuity of therapy and reduces dangerous gaps during intra-hospital transfers.