Chapter 1

Question 1

QSEN

Answer 1

Quality and Safety in Nursing Education.

This format used to id expected KSA behavior for each CCTM dimension

Question 2

KSA

Answer 2

Knowledge, Skills and Attitudes, summarizes behavioral expectations for each CCTM competency

Question 3

What does the CCTM Model include?

Answer 3

a. Specifies the dimensions of CCTM and the associated competencies needed to be performed with the model

Question 4

What is the vision for the Core Curriculum as the Foundation for the CCTM Model?

Answer 4

1. The vision of CCTM Model is to standardize the work of amb, acute, subacute, and home care health care providers using evidence from interdisciplinary literature on CCTM.
2. Uses the CCTM Model
   3.Consistent with QSEN mission and vision
3. Consistent with Institute of Medicine’s Report; The Future of Nursing: Leading Change Advancing Health- RNs are full partners with providers and other health care professionals in redesiging health care in US
4. Consistent with ANA book, Care Coordination: The Game Changer
5. Consistent with the work of national professional organizations, i.e.
   ANA Position Statement, ANA white paper, ANA Framework for Measuring Nurses’ Contribution to Care Coordination, ANA’s Care Coordination Quality Measures Panel, AAN, American Academy of Nursing, AAN’s summary of the importace of health infomation technology in cctm
   Ch 1 Introduction

Question 5

Definition of Competency integrates what 3 things?

Answer 5

Performing successfully at an expected level integrating knowledge, skills, abilities, and judgement.

Question 6

Definition of Care Coordination

Answer 6

The deliberate organization of patient care activities between two or more participants (including the pt) involved in a pt’s care to facilitate he appropriate delivery of health care services. “Exchange of info among participants responsible for different aspects of care” Deliver the right care (and only the right care) to the right pt at the right time.
Ch 1 Introduction

Question 7

Definition of Transition Management

Answer 7

“A broad range of time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another” “The ongoing support of pts and families over time as they navigate care among more than one provider and/or more than one health care setting and more than one health care service.”

Question 8

What is the basis for the CCTM model?

Answer 8

Individulized plans of care and f/u plans of care. Pt centered, interprofessional collaborative, RN role as CCTM.

Question 9

Half of health care spending in the US is spent on what what percent of the population?

Answer 9

5%

Question 10

What is the Triple Aim?

Answer 10

Institute for Health Care Improvement: (EHC = experience, health, cost)

1. Improve individual experience of care
2. Improve health of populations
3. Reduce the percapita cost of care for populations

Question 11

What is the traditional “rescue care” approach to health care?

Answer 11

Frequent ED visits and hospitaizations

Question 12

CCTM Model in relation to Affordable Care Act

Answer 12

RNs independent, essential role in Care Coordination, team member PCMH, focus on access to prim care vs increased use specialists and acute care, care coord for complex ill pts across the care continuum, pt-centered care plans, extant models of care for chron ill in community staffed by RN, CMS administers Accountable Care Organization program, Partnerships for Patients program to make care safer and improve care transitions, billing codes for APNs, not RNs, the value modifier (differential payment based on quality of care provided compared to cost during a defined performance period -CMS 2014

Question 13

What is PACT Model?

Answer 13

Patient Aligned Care Team, the
patient-centered medical home model
(includes specialty care, women’s healthcare, geriatrics, and academic training programs, began with VA and non-VA care coordination and collaboration

Question 14

Who are the members in the PACT?

Answer 14

1. Pt in center
2. Family members
3. Care givers
4. Health care professionals including pcp, RNCM, MA, AA
   The PACT, when other services are needed to meet pt goals and needs, oversees and coordinates that care

Question 15

What is Guided Care Model

Answer 15

Care is drive by highly skilled RN in primary care office assisting 3-4 providers for chronic care needs, high-risk pts with several chronic conditions and complex health care needs in primary care practice

Question 16

Predictive modeling software does what?

Answer 16

Analyze pt encounter data for previous year, “hierarchical condition category” software points to each diagnosis and computes a risk rating for each pt

Question 17

What is a TOE?

Answer 17

table of evidence

Question 18

What are the 9 evidence-based dimensions of CCTM?

Answer 18

1. Self management
2. Education and engagement of pt and family
3. Cross setting communication and transition
4. Coaching and counseling of pts and families
5. Nursing process including assessment, plan, implementation/intervention, and evaluation; a proxy for monitoring and intervening
6. Teamwork and collaboration
7. Pt-centered care planning
8. Decision support and information systems
9. Advocacy

Question 19

Logic Model

Answer 19

Used to guide the organization of the chapters to ID activities and processes and outcomes involved in each of the dimensions. Main outcomes were
ED visits and hospital re-admission rates.

Question 20

CMS is what?

Answer 20

Centers for Medicare and Medicaid Services

Question 21

What is the end result of End of Life advance decision making?

Answer 21

Cuts cost of care and reduces pain and suffering.