CPHQ Care Transition Processes 4 — Questions and Answers
Question 1: A patient is transitioning from acute care to home health services. The primary care physician has not received the discharge summary 5 days post-discharge. This represents a failure in which domain of care transitions?
- Patient activation
- Information transfer (Correct answer)
- Follow-up care coordination
- Medication reconciliation
Correct answer: Information transfer
Timely and complete information transfer to outpatient and community providers is a critical domain of successful care transitions; delays create significant safety gaps.
Question 2: Which quality improvement framework is MOST commonly used to structure care transition improvement projects in healthcare organizations?
- Six Sigma DMAIC
- Plan-Do-Study-Act (PDSA) cycles (Correct answer)
- Root Cause Analysis (RCA)
- Failure Mode and Effects Analysis (FMEA)
Correct answer: Plan-Do-Study-Act (PDSA) cycles
PDSA cycles are the most commonly applied QI framework for iterative testing and implementing care transition improvements in clinical settings.
Question 3: A CPHQ candidate is reviewing a care transition program's outcomes. Which measure best captures the patient experience dimension of a transition?
- 30-day readmission rate
- CTM-3 (Care Transitions Measure) patient survey score (Correct answer)
- Time to post-discharge follow-up appointment
- Discharge summary completion rate within 24 hours
Correct answer: CTM-3 (Care Transitions Measure) patient survey score
The CTM-3 is a validated patient-reported survey measuring patients' perceptions of preparation, medication understanding, and care continuity during transitions.
Question 4: During a care transitions audit, a quality professional finds that 40% of patients discharged with new prescriptions had at least one discrepancy between their discharge medication list and what was actually prescribed. The FIRST corrective action should be:
- Implementing automatic pharmacy refill programs for all discharge medications
- Requiring a dual-pharmacist verification process for all new prescriptions
- Standardizing the medication reconciliation process at discharge with pharmacist involvement (Correct answer)
- Educating patients to cross-check their own discharge medication lists
Correct answer: Standardizing the medication reconciliation process at discharge with pharmacist involvement
Standardizing discharge medication reconciliation with active pharmacist involvement addresses the root systemic cause of prescription discrepancies at the point of transition.
Question 5: A hospital's readmission reduction team wants to stratify patients by readmission risk at discharge. Which tool is designed for this purpose in the care transitions context?
- APACHE II scoring system
- LACE Index (Length of stay, Acuity, Comorbidity, ED visits) (Correct answer)
- NEWS (National Early Warning Score)
- Braden Scale for pressure injury risk
Correct answer: LACE Index (Length of stay, Acuity, Comorbidity, ED visits)
The LACE Index combines length of stay, acuity of admission, comorbidity burden, and ED visit history to predict 30-day readmission risk at the time of discharge.
Question 6: A care transitions nurse coordinator is planning post-discharge follow-up for a complex patient. Evidence supports that the follow-up contact should occur within what timeframe to be most effective in preventing readmission?
- Within 1 week of discharge
- Within 48-72 hours of discharge (Correct answer)
- Within 24 hours of discharge
- Within 2 weeks of discharge
Correct answer: Within 48-72 hours of discharge
Evidence consistently shows that follow-up contact within 48-72 hours of discharge is most effective in identifying emerging problems before they lead to readmission.
Question 7: Social determinants of health (SDOH) most directly impact care transitions when a patient:
- Refuses to sign discharge paperwork
- Lacks transportation, housing stability, or medication affordability after discharge (Correct answer)
- Disagrees with the treating physician's discharge diagnosis
- Has a language preference other than English for written materials only
Correct answer: Lacks transportation, housing stability, or medication affordability after discharge
Transportation barriers, housing instability, and medication costs are SDOH factors that directly prevent patients from successfully completing post-discharge care plans.
CPHQ Care Transition Processes 4
A patient is transitioning from acute care to home health services.
The primary care physician has not received the discharge summary 5 days post-discharge.
This represents a failure in which domain of care transitions?