chap 12 interprofessional collaborative practice & care coordination

Question 1

care coordination

Answer 1

deliberate organization of patient care acts btwn 2 or more participants (including the patient) to facilitate the appropriate delivery of quality health care services in an efficient person-centered manner; mechanism to make sure the patients get the right care at the right time in the most efficient and cost-effective manner, by the right person in the right setting

Question 2

care coordinator

Answer 2

care provider (nurse case manager, social worker, community health worker, or lay person) who is responsible for identifying a person’s health goals and coordinating services and providers to meet those goals

Question 3

care transition

Answer 3

continuous process in which a patient’s care shifts from being provided in one setting of care to another

Question 4

collab prac

Answer 4

what happens when mult health workers from diff professional backgrounds work together w patients, families, carers, and communities to deliver the highest quality of care

Question 5

community-based care

Answer 5

health care that is provided to ppl who live w in a defined geographic region or who have common needs; designed to meet the needs of ppl as they move btwn and among health care settings

Question 6

continuity of care

Answer 6

coordination of services provided to pts before they enter a health care setting, during the time they are in the setting, and after they leave the setting

Question 7

discharge planning

Answer 7

systematic process of preparing the pt to leave the health care facility and for maintaining continuity of care

Question 8

home health care

Answer 8

agency eligible to receive fed funds that provides home-based health care; may be independent, hospital operated, or health department managed

Question 9

medication reconciliation

Answer 9

process of creating an accurate list of all medications a pt is taking, including drug name, dosage, freq, and route, and comparing the list to the physician’s admission, transfer, or discharge orders, w the goal of providing correct meds to the pt at all transition points w in the hospital

Question 10

patient handoffs

Answer 10

transferring responsibility for a pt from 1 caregiver to another w the goal of providing timely, accurate info abt a pt’s plan of care, treatment, current condition, and anticipated changes

Question 11

telehealth

Answer 11

use of electronic info and telecommunication technologies to provide care when the pt and the clinician are not in the same place at the same time

Question 12

Healthy People 2030

Answer 12

defines Leading Health Indicators (LHls) for communities

Question 13

IRS requires not-for-profit hospitals to conduct…

Answer 13

community health needs assessments for their surrounding communities to demonstrate how they are meeting their needs

Question 14

Roles of C/PHN

Answer 14

-patient advocate
-coordinator of services
-educator/counselor

Question 15

CUS (continuity of care strategy)

Answer 15

-I am Concerned
-I am Uncomfortable
-I believe Safety is at risk

Question 16

Strategies on hospital floor

Answer 16

-Consultation
-Referral
-Safety huddles
-Patient rounds
-Safety rounds
-Daily goal ws/wb
-Shared care plans
-Structured fam meetings
-Shared training (CE and inservices for mult specialties)

Question 17

Nurse navigator

Answer 17

-clinically-trained nurse
-central point of contact for pt care
-identifies and removes barriers to treatment

Question 18

Pt navigator

Answer 18

-Can be nurse, social worker, or lay person
-Focuses on the support aspects of care

Question 19

Ambulatory care (office/clinic/short-stay)

Answer 19

-Pt is receiving care, but not staying overnight
-Short health history
-If same-day SX, screening tests, teaching, and admission takes place before the pt enters the setting

Question 20

Patient is legally free to leave at any time…

Answer 20

However, this choice carries a risk for increased illness or complications

Question 21

Telehealth/Telemed

Answer 21

Used for:
-Wellness visits
-Med refills/prescriptions
-Dermatology
-Nutrition counseling
-Mental health counseling
-Some urgent care conditions

Question 22

incivility

Answer 22

uncivil or bullying tactic

Question 23

situation monitoring

Answer 23

helps the team to be aware and understand the team’s performance and the impact on pt’s outcomes

Question 24

ISBARR (communication)

Answer 24

intro, situation, background, assessment, recommendation, readback
*** reduces risk of lost info and misinform during change-of-shift

Question 25

cognitive rehearsal

Answer 25

mentally rehearsing before vocalizing or implementing an action during an anxiety-inducing situation