Interprofessional collaborative practice and care coordination across settings

Question 1

What are some socioeconomic needs?

Answer 1

employment
Crime/ neighborhood safety
housing/ homelessness
education
food
environment

Question 2

What are some direct health needs?

Answer 2

Behavioral health
substance abuse
mental health
chronic disease
mental health
uninsured/ underinsured

Question 3

Nurse navigator role

Answer 3

Identifies and removes barriers to treatment
Clinically trained nurse
Central point of contact for patient care

Question 4

Patient Navigator role

Answer 4

Nurse
Social Worker
Lay person
Focuses on support aspects of care

Question 5

When patient is admitted, what information will you obtain?

Answer 5

Name, address, DOB
Gender and marital status
Name of admitting physician
Name of nearest relative
Occupation and employer
Financial status for health care payment
Religious preference
Date and time of admission/ admission diagnosis
Identification number

Question 6

Essential components of discharge planning

Answer 6

Assess strengths and limitations of patient, family, or support person
Assess the environment
Implement and coordinate the care plan
Consider individual, family, and community resources
Evaluate effectiveness of care

Question 7

Criteria for Formal Discharge and Referral

Answer 7

Lack of knowledge of treatment plan
Social Isolation
Recently diagnosed chronic disease
Major surgery
Prolonged recuperation
Emotional instability
Complex home regimen
Financial Difficulties
Lack of available or appropriate referral resources
Terminal Illness

Question 8

Guidlines for discharge planning

Answer 8

Assess and identify healthcare needs
Set goals with patient
Teach patient and family
Provide home health care referrals
Evaluate discharge planning effectiveness