Multidisciplinary Care Planning & Coordination Flashcards

Under Medicare IRF coverage criteria, how often must the interdisciplinary team conference be held for a stroke patient?

Answer: At least once per week

Medicare requires IRF interdisciplinary team conferences at least once a week, led by the rehabilitation physician, to review progress and revise goals.

Which team model is characterized by members sharing roles and crossing discipline boundaries, with one primary provider delivering much of the care?

Answer: Transdisciplinary

Transdisciplinary teams use role release so one member can deliver integrated care drawn from several disciplines.

A stroke survivor is coughing during meals and has a wet voice after drinking. Which team member should the rehab specialist refer to first?

Answer: Speech-language pathologist

The SLP evaluates and manages oropharyngeal dysphagia, including instrumental swallow studies.

Which framework is commonly used to structure stroke rehab goals across body function, activity, and participation domains?

Answer: ICF (International Classification of Functioning, Disability and Health)

The WHO ICF model organizes function at the body structure/function, activity, and participation levels plus contextual factors.

In an IRF, within what timeframe must the individualized overall plan of care be completed?

Answer: Within the first 4 days of admission

CMS requires the rehabilitation physician to complete the individualized plan of care within the first 4 days of the IRF stay.

Which team member is primarily responsible for medication reconciliation at transitions of care?

Answer: Pharmacist working with the prescribing physician

Pharmacists, alongside prescribers, reconcile medication lists to prevent errors at admission, transfer, and discharge.

A goal written as 'Patient will walk 150 feet with a quad cane and supervision within 2 weeks' best demonstrates which goal-writing principle?

Answer: SMART goal

It is Specific, Measurable, Achievable, Relevant, and Time-bound.