Guided Care Flashcards
What is the goal of the guided care nurse?
To work in partnership with the primary care physician, the patient and their caregiver, staff, etc, to attain the goals of Guided Care.
What are the 2 goals of Guided Care?
1: To Maximize the quality of life for chronically ill patients.
2: Maximize the quality and efficiency of their healthcare.
In the ABC approach to heart disease prevention, what does the B stand for?
Blood pressure management
What are the 8 primary care activities of a guided care nurse?
Assessing the patient at home, Developing evidence based plans, Monitoring the patient’s condition, Engaging the patient in self management, Coordinating the efforts of all professionals, Smooting
In the ABC approach to heart disease prevention, what does the A stand for?
Anti platelet therapy
Which of the following is the highest priority for the GCN? Transitional care, Returning Ad Hoc calls, Completing documentation, monitoring and coaching contacts?
Transitional Care.
How often is it recommended to have a “touch base” with a caregiver?
Every 3 months.
In what timeframe should a GCN arrange a home visit with a patient discharged from a facility?
Within 1 to 2 days.
What is one of the number one strategies for coaching non-adherent patients?
Refocus on patient’s personal health goals.
A transitional care goal of the GCN is to deliver the Care Guide to the inpatient providers within how soon after admission?
24 hours.
In Transitional Care, how many responsibilities does the GC nurse have?
Five
What is the interviewing technique used by Guided Care nurses called?
Motivational Interviewing
OARS is a core element of Motivational Interviewing. What does OARS stand for?
O: Open ended questions
A: Affirmation
R: Reflection
S: Summary
Name the key responsibilities of the GC nurse during transitional care:
- Ensure that inpatient team has current Care Guide within 24 hours of admission.
- Monitor patient’s status daily.
- Prepare patient and caregiver for discharge.
- Visit patient within 1-2 days of discharge.
- Keep PCP informed of patient’s status.
List 3 methods for determining which patients would be eligible for Guided Care.
Risk Score
PCP’s clinical judgement
Patient Survey
True or False: Those who write down their treatment preferences while alive are more likely to receive those cares than those who do not.
TRUE
Name 3 benefits of stating healthcare preferences in an advanced directive.
- Fam and friends will know and be more likely to support the kind of care you want.
- HCP will know/be obligated to give you only types of care you want.
- You will be more likely to receive care you want.
According to MI, what are the 2 components that help determine motivation to change.
Importance and Confidence.
What are the 2 primary clinical activities in which GCN use MI most frequently?
- Meeting with patients to identify goals and preferences.
2. During monthly monitoring and coaching contacts.
List the 3 most important characteristics of effective clinical presentations to physicians and other providers .
- Organize information.
- Use clear and straightforward language.
- Be concise.
What communication tool is a preferred tool for presenting clinical situations to a PCP?
SBAR
What does Medicare Part A apply to?
Hospital care
What does Medicare Part B apply to?
Physician and Outpatient care
What does Medicare Part C apply to?
Medicare Advantage plans
What does Medicare Part D apply to?
Prescription drugs
True or False, Medicare Part A has a monthly premium.
False
What Part of Medicare covers outpatient DME?
Part B
What percentage of the cost of DME for the home does the patient generally pay?
20%
True or False, Medicare Part D recipients pay a monthly premium.
TRUE
True or False, Medicare Part D does not require recipients to meet a deductible.
FALSE. The
Medicare Part D plans usually require “co-insurance” to be paid for each prescription. Explain this and the “donut hole”.
Typically, patients are responsible for a 25% copay on their prescriptions. After their medications cost a certain amount, the patient is responsible for 100% of the cost of the medications. This is called the donut hole.
Name 3 sources where information for the Initial Assessment can be collected from.
- Medical Record
- Patient
- Caregiver or proxy
Name some conditions in which the GCN completes a condition specific assessment.
Hypertension, Insomnia, Constipation, Dementia, COPD, Persistent Pain, Falls, Diabetes
Patient Caregivers: What is the definition of Caregivers.
Caregiver: relatives or unpaid non-relatives who are identified by the patient as helping out regularly with personal care, household, or health-related tasks.
According to the GC model, how many steps are there in the Care Planning process?
4
What are the steps to GC Care Planning process.
- Care planning begins and ends with the patient. 2. Data from initial assessment is entered into HIT to create prelim Care Guide. 3. Review prelim Care Guide with PCP. 4. Translate Care Guide into patient friendly Action Plan.
Name the 6 processes of Ongoing Guided Care.
- Monitor patient’s chronic conditions. 2. Coaching patients for self management. 3. Supporting caregivers. 4. Facilitating access to community based services. 5. Coordinating services across providers and sites of care. 6. Managing transitions.
In the Monitoring process of Ongoing Guided Care, what are the goals for the GCN.
- Review adherence to the Action Plan.
2. Inquire about changes in health status.
Other than smoothing transitions, what is the other top priority in organizing the GCN’s day?
Returning Ad Hoc calls.
How many attempts should be made to contact a patient before a letter, etc, is sent?
3 times.
List 3 methods for determining which patients would be eligible for Guided Care.
Risk Score
PCP’s clinical judgement
Patient Survey
True or False: Those who write down their treatment preferences while alive are more likely to receive those cares than those who do not.
TRUE
Name 3 benefits of stating healthcare preferences in an advanced directive.
- Fam and friends will know and be more likely to support the kind of care you want.
- HCP will know/be obligated to give you only types of care you want.
- You will be more likely to receive care you want.
According to MI, what are the 2 components that help determine motivation to change.
Importance and Confidence.
What are the 2 primary clinical activities in which GCN use MI most frequently?
- Meeting with patients to identify goals and preferences.
2. During monthly monitoring and coaching contacts.
List the 3 most important characteristics of effective clinical presentations to physicians and other providers .
- Organize information.
- Use clear and straightforward language.
- Be concise.
What communication tool is a preferred tool for presenting clinical situations to a PCP?
SBAR
What does Medicare Part A apply to?
Hospital care
What does Medicare Part B apply to?
Physician and Outpatient care
What does Medicare Part C apply to?
Medicare Advantage plans
What does Medicare Part D apply to?
Prescription drugs
True or False, Medicare Part A has a monthly premium.
False
What Part of Medicare covers outpatient DME?
Part B
What percentage of the cost of DME for the home does the patient generally pay?
20%
True or False, Medicare Part D recipients pay a monthly premium.
TRUE
True or False, Medicare Part D does not require recipients to meet a deductible.
FALSE. The
Medicare Part D plans usually require “co-insurance” to be paid for each prescription. Explain this and the “donut hole”.
Typically, patients are responsible for a 25% copay on their prescriptions. After their medications cost a certain amount, the patient is responsible for 100% of the cost of the medications. This is called the donut hole.
Name 3 sources where information for the Initial Assessment can be collected from.
- Medical Record
- Patient
- Caregiver or proxy
Name some conditions in which the GCN completes a condition specific assessment.
Hypertension, Insomnia, Constipation, Dementia, COPD, Persistent Pain, Falls, Diabetes
Patient Caregivers: What is the definition of Caregivers.
Caregiver: relatives or unpaid non-relatives who are identified by the patient as helping out regularly with personal care, household, or health-related tasks.
According to the GC model, how many steps are there in the Care Planning process?
4
What are the steps to GC Care Planning process.
- Care planning begins and ends with the patient. 2. Data from initial assessment is entered into HIT to create prelim Care Guide. 3. Review prelim Care Guide with PCP. 4. Translate Care Guide into patient friendly Action Plan.
Name the 6 processes of Ongoing Guided Care.
- Monitor patient’s chronic conditions. 2. Coaching patients for self management. 3. Supporting caregivers. 4. Facilitating access to community based services. 5. Coordinating services across providers and sites of care. 6. Managing transitions.
In the Monitoring process of Ongoing Guided Care, what are the goals for the GCN.
- Review adherence to the Action Plan.
2. Inquire about changes in health status.
Other than smoothing transitions, what is the other top priority in organizing the GCN’s day?
Returning Ad Hoc calls.
How many attempts should be made to contact a patient before a letter, etc, is sent?
3 times.
Health Information Technology is essential in Guided Care for:
- Creating Prelim Care Guides
- Checking for Drug interactions
- Reminders
- Documenting encounters
- Other functions that support Guided Care
True or False: Condition specific forms should be filled out for each of the patient’s chronic conditions during the initial assessment?
TRUE
How many millions of caregivers provide how many billions of dollars in “free” caregiving annually?
50 million caregivers provide 250 billion dollars in care annually.
How many hours does the average unpaid caregiver provide in care weekly?
21 hours (2007 AARP study)
What do unpaid caregivers say they need most
Validation of their caregiver role and for it to be seen as meaningful.
What are 5 goals of assessing caregiver?
- Rapport
- Assess help caregiver provides
- Learn challenges
- Provide opportunity for caregiver to state needs.
- Address caregivers needs
What is a Care Guide?
An evidence based care plan that reflects the goals and intentions of the patient, caregiver, physician and nurse.
What are 3 of the framing elements that are used to frame a discussion with PCP about Preliminary Care Guide?
- Patient priorities
- Nurse impressions
- Chronic conditions
What is an action plan?
It is the patient friendly version of the Care Guide.
What is the purpose of the monitoring call? (Mod 13)
Detect and address emerging problems and non-adherence to self-management
What are 8 tasks of Monitoring/Coaching
- Initiation (how often)
- Inquire about status / Review Action plan
- Assess adherence
- F/U Community referrals
- Coach on specific topics
- Follow up plan w/ patient
- Update Action Plan
- Document
How often does the average COPD patient have exacerbations and what number identifies the patient as more frequent?
1-4, and greater than 2
What is the most frequent cause of COPD exacerbation?
Bacterial infection (30-50%), followed by Viral infection (30%)
What % LVEF constitutes heart failure?
40% or less
