Transitions of Care & Care Coordination Flashcards

Which of the following care transition models is MOST associated with pharmacist-led medication reconciliation and patient self-management coaching?

Answer: The Coleman Care Transitions Intervention (CTI)

The Coleman Care Transitions Intervention uses transition coaches — including pharmacists — to promote medication self-management, follow-up appointments, and personal health record use during post-discharge periods.

A patient with type 2 diabetes is transferred to home health after amputation surgery. The MTM pharmacist notes insulin was not included on the home health medication order. This omission is BEST classified as:

Answer: An error of omission — a critical medication was not carried forward

Failure to carry forward a critical medication like insulin constitutes an error of omission during care transition, which can lead to dangerous hyperglycemia or diabetic ketoacidosis.

Which strategy is MOST effective at ensuring medication adherence in the immediate post-discharge period for patients with low health literacy?

Answer: Using teach-back with a simplified visual medication schedule

Teach-back combined with a visual, simplified medication schedule confirms patient understanding and compensates for low health literacy, which is a major driver of non-adherence after discharge.

An MTM pharmacist receives a referral for a patient who was just discharged from a psychiatric inpatient unit. The patient's outpatient psychiatrist was not informed of the medication changes. The pharmacist's PRIMARY coordination task is to:

Answer: Contact the outpatient psychiatrist to transmit the discharge medication list and identify discrepancies

Closing the communication gap between inpatient and outpatient psychiatric providers prevents medication errors, ensures continuity of mental health treatment, and is a core MTM coordination responsibility.

Which metric is MOST directly tied to the effectiveness of pharmacist-led MTM during care transitions in reducing hospital readmissions?

Answer: 30-day all-cause hospital readmission rate

The 30-day all-cause readmission rate is the most widely used outcome metric for evaluating transition-of-care programs, including MTM, as it directly measures whether interventions prevented return hospitalizations.

A patient newly started on a direct oral anticoagulant (DOAC) is being transitioned from hospital to home. Which counseling point is MOST critical for the MTM pharmacist to address?

Answer: Adherence to dosing schedule, signs of bleeding, and the need to inform all providers of DOAC use

DOACs require strict adherence, prompt recognition of bleeding signs, and disclosure to all providers to avoid dangerous drug interactions — DOAC monitoring does not require INR testing unlike warfarin.

When performing a post-discharge MTM visit, the pharmacist identifies a patient is taking both a brand-name drug dispensed at hospital discharge and its generic equivalent purchased at a retail pharmacy. This represents:

Answer: Therapeutic duplication — an unintentional doubling of the same medication

Receiving both a brand and its generic equivalent simultaneously is therapeutic duplication — a common care transition error that can lead to toxicity and must be resolved by having the patient discontinue one of the two.