transition of care

Question 1

Which of the following factors contributes to almost half of all medication errors during transitions of care?

A) Failure to provide discharge education
B) Inaccurate or incomplete information transfer
C) Delayed hospital admission
D) Patient non-compliance with medication regimens

Answer 1

Correct answer: B) Inaccurate or incomplete information transfer

Question 2

Question 2:
Which of the following is a recommended strategy to improve transitions of care during hospital discharge?

A) Scheduling the follow-up appointment for the patient before discharge
B) Providing verbal discharge instructions only
C) Encouraging patients to schedule their own follow-up appointments
D) Waiting until the day of discharge to begin discharge planning

Answer 2

Correct answer: A) Scheduling the follow-up appointment for the patient before discharge

Question 3

Question 3:
Which patient is at the highest risk for experiencing a suboptimal transition of care?

A) A 60-year-old patient with stable hypertension transitioning from hospital to home
B) An 80-year-old patient with multiple chronic conditions and limited support at home
C) A 75-year-old patient transitioning from hospital to skilled nursing with adequate home care services arranged
D) A 65-year-old patient with a strong support system transitioning from hospital to rehab

Answer 3

Correct answer: B) An 80-year-old patient with multiple chronic conditions and limited support at home

Question 4

Question 4:**
What is a key component of the Community-Based Care Transitions Program (CCTP) aimed at reducing hospital readmissions?

A) Providing nurse-led education to patients only during their hospital stay
B) Coordinating care among medical and community resources post-discharge
C) Reducing the length of hospital stay
D) Discharging patients without follow-up to ensure quick bed turnover

Answer 4

Correct answer: B) Coordinating care among medical and community resources post-discharge

Question 5

Question 5:
Which of the following steps is crucial for preventing hospital readmissions within 30 days of discharge?

A) Initiating discharge planning immediately before discharge
B) Ensuring accurate and timely transfer of patient information to the next provider
C) Encouraging patients to follow up with their providers at their convenience
D) Discharging patients as quickly as possible to reduce hospital costs

Answer 5

Correct answer: B) Ensuring accurate and timely transfer of patient information to the next provider

Question 6

Question 6:
What is one benefit of initiating discharge planning at the beginning of a patient’s hospital stay?

A) Reduces the need for follow-up appointments
B) Prevents the development of multimorbidities
C) Enhances the coordination of post-discharge care and reduces readmission risk
D) Ensures that all care is provided within the hospital setting

Answer 6

Correct answer: C) Enhances the coordination of post-discharge care and reduces readmission risk

Question 7

Question 8:
Which of the following is a significant barrier to safe transitions of care?

A) Early discharge planning
B) Proper medication reconciliation
C) Lack of provider education and feedback
D) Adequate follow-up support after discharge

Answer 7

Correct answer: C) Lack of provider education and feedback

Question 7

Question 7:
Which of the following is a characteristic of suboptimal transitions of care?

A) Thorough medication reconciliation during discharge
B) Early involvement of home-care services
C) Delayed or lack of follow-up care after discharge
D) Comprehensive patient education before discharge

Answer 7

Correct answer: C) Delayed or lack of follow-up care after discharge

Question 8

Question 9:
In the Re-Engineered Discharge (RED) Project, which intervention was shown to reduce hospital readmissions?

A) Providing patient-centered discharge instructions and follow-up calls
B) Delaying discharge until all tests are completed
C) Allowing patients to self-manage their medications without review
D) Reducing the length of hospital stay without further coordination

Answer 8

Correct answer: A) Providing patient-centered discharge instructions and follow-up calls

Question 9

Question 10:
What is one of the goals of the Geriatric Resources for Assessment and Care of Elders (GRACE) initiative?

A) Increasing emergency department visits for early intervention
B) Reducing nursing home admissions and improving care transitions
C) Encouraging patients to rely more on emergency services
D) Eliminating the need for interprofessional team collaboration

Answer 9

Correct answer: B) Reducing nursing home admissions and improving care transitions

Question 10

Question 11:
Which of the following patient factors increases the risk of a suboptimal transition?

A) Stable income and strong family support
B) Multiple chronic conditions and lack of home-care services
C) Being discharged to a skilled nursing facility with a coordinated care plan
D) High health literacy and regular primary care follow-up

Answer 10

Correct answer: B) Multiple chronic conditions and lack of home-care services

Question 11

Question 12:
Which step is critical for ensuring an optimal transition from hospital to home?

A) Providing the patient with verbal instructions only
B) Scheduling a follow-up appointment for the patient with their primary care provider
C) Allowing patients to arrange their own care after discharge
D) Reducing the discharge process to save time

Answer 11

Correct answer: B) Scheduling a follow-up appointment for the patient with their primary care provider

Question 12

Question 13:**
Which of the following is an example of suboptimal care during transitions?

A) Initiating discharge planning during admission
B) Failing to transfer accurate medication information during handoff
C) Scheduling follow-up appointments for patients prior to discharge
D) Coordinating community resources to assist with post-discharge care

Answer 12

Correct answer: B) Failing to transfer accurate medication information during handoff

Question 13

Question 14:
What is a key intervention to reduce hospital readmissions within 30 days of discharge?

A) Conducting a thorough comprehensive assessment only at the time of discharge
B) Providing patients with written instructions but no follow-up
C) Ensuring continuity of care by involving both hospital and community-based providers
D) Delaying discharge until all diagnostic tests are completed, regardless of patient status

Answer 13

Correct answer: C) Ensuring continuity of care by involving both hospital and community-based providers

Question 14

Question 15:
The Community-Based Care Transitions Program (CCTP) primarily targets which population to improve care transitions?

A) Pediatric patients with complex care needs
B) Medicare beneficiaries at risk for hospital readmission
C) Patients requiring emergency care frequently
D) Young, healthy adults with no chronic conditions

Answer 14

Correct answer: B) Medicare beneficiaries at risk for hospital readmission

Question 15

Question 16:
Which of the following is a patient-level risk factor for suboptimal transitions of care?

A) High socioeconomic status
B) Poor self-management ability
C) Comprehensive discharge instructions
D) Early identification of home-care needs

Answer 15

Correct answer: B) Poor self-management ability

Question 16

Question 17:
Which of the following interventions is part of a comprehensive medication review to improve care transitions?

A) Allowing patients to self-administer medications without review
B) Discontinuing all medications after hospital discharge
C) Reconciling pre-hospital medications with discharge medications
D) Providing verbal-only medication instructions

Answer 16

Correct answer: C) Reconciling pre-hospital medications with discharge medications

Question 17

Question 19:
Which of the following strategies is most effective in minimizing medication errors during transitions of care?

A) Waiting until discharge to perform medication reconciliation
B) Conducting a thorough medication reconciliation at admission, discharge, and follow-up
C) Relying on patients to remember their medications after discharge
D) Discontinuing all previous medications when new medications are prescribed

Answer 17

Correct answer: B) Conducting a thorough medication reconciliation at admission, discharge, and follow-up

Question 18

Question 18:
What is the primary goal of discharge planning for older adults?

A) Reducing hospital length of stay
B) Preventing 30- and 90-day hospital readmissions
C) Transitioning patients to skilled nursing facilities quickly
D) Ensuring patients manage all aspects of care on their own

Answer 18

Correct answer: B) Preventing 30- and 90-day hospital readmissions

Question 19

Question 20:
What is one of the main goals of the Affordable Care Act (ACA) related to transitions of care?

A) Increasing hospital admissions for Medicare beneficiaries
B) Reducing 30-day readmission rates and improving care coordination
C) Delaying discharge to avoid premature transitions
D) Encouraging patients to manage their transitions independently without provider input

Answer 19

Correct answer: B) Reducing 30-day readmission rates and improving care coordination

Question 20

Question 21:
Which of the following elements is critical to ensuring an optimal transition of care for older adults?

A) Educating only the patient about their diagnosis
B) Coordinating logistics for follow-up care, such as home health or medical equipment
C) Assuming the patient will manage their own medication regimen
D) Discharging patients with verbal instructions and no written discharge summary

Answer 20

Correct answer: B) Coordinating logistics for follow-up care, such as home health or medical equipment

Question 21

Question 22:
Which of the following is a systems-level risk factor for suboptimal transitions?

A) Low hospital readmission rates
B) High hospital admission rates and insufficient communication between settings
C) Comprehensive discharge planning
D) Adequate support and care coordination post-discharge

Answer 21

Correct answer: B) High hospital admission rates and insufficient communication between settings

Question 22

Question 23:
Which of the following programs focuses on reducing emergency department visits, hospital readmissions, and nursing home placements for older adults with complex needs?

A) Community-Based Care Transitions Program (CCTP)
B) Re-Engineered Discharge (RED) Project
C) Geriatric Resources for Assessment and Care of Elders (GRACE)
D) Medicare Beneficiary Care Program (MBCP)

Answer 22

Correct answer: C) Geriatric Resources for Assessment and Care of Elders (GRACE)

Question 23

Question 24:
What role does patient empowerment play in optimizing transitions of care?

A) It removes the need for follow-up care.
B) It helps patients take ownership of their health and assert their preferences.
C) It allows healthcare providers to minimize communication with the patient.
D) It eliminates the need for medication reconciliation.

Answer 23

Correct answer: B) It helps patients take ownership of their health and assert their preferences.

Question 24

Question 25:
Which of the following is a common adverse event associated with suboptimal transitions of care?

A) Increased patient satisfaction
B) Timely follow-up appointments
C) Delayed diagnosis and treatment
D) Comprehensive patient education

Answer 24

Correct answer: C) Delayed diagnosis and treatment

Question 25

Question 26:
The process of ensuring that all patient care information is communicated effectively during transitions is known as:

A) Patient advocacy
B) Care coordination
C) Medication reconciliation
D) Discharge planning

Answer 25

Correct answer: B) Care coordination

Question 26

Question 27:
A follow-up phone call after discharge is primarily intended to:

A) Reduce hospital stay length
B) Replace the need for outpatient visits
C) Ensure the patient understands discharge instructions and is managing care
D) Encourage patients to seek care only when symptoms worsen

Answer 26

Correct answer: C) Ensure the patient understands discharge instructions and is managing care

Question 27

Question 28
Which of the following interventions is essential for a patient transitioning to a skilled nursing facility?

A) Immediate discharge without a care plan
B) Detailed transfer of medical records and care instructions
C) Allowing the facility to create a care plan independently after the patient arrives
D) Minimizing communication between hospital and facility staff

Answer 27

Correct answer: B) Detailed transfer of medical records and care instructions

Question 28

Question 29:
What is a primary focus of the Community-Based Care Transitions Program (CCTP)?

A) To increase the number of patients receiving home health services
B) To enhance hospital revenue through longer patient stays
C) To prevent hospital readmissions by improving post-discharge care coordination
D) To reduce the role of primary care providers in follow-up care

Answer 28

Correct answer: C) To prevent hospital readmissions by improving post-discharge care coordination

Question 29

Question 30:**
Which patient scenario is most likely to result in a suboptimal transition of care?

A) A patient with a clear, written discharge plan and scheduled follow-up
B) A patient discharged with incomplete medication information and no follow-up appointment
C) A patient who receives a home health visit within 24 hours of discharge
D) A patient whose primary care provider is updated promptly with discharge information

Answer 29

Correct answer: B) A patient discharged with incomplete medication information and no follow-up appointment

Question 30

Question 31:
Which statement best describes the impact of suboptimal transitions on healthcare costs?

A) They decrease overall healthcare costs by reducing unnecessary care.
B) They have no significant impact on healthcare costs.
C) They increase costs due to higher rates of readmission and adverse events.
D) They only impact costs for patients without insurance.

Answer 30

Correct answer: C) They increase costs due to higher rates of readmission and adverse events

Question 31

Question 32:
What is one of the main reasons older adults are particularly vulnerable to suboptimal transitions of care?

A) They often have a single, well-managed chronic condition.
B) They typically have fewer medications to manage.
C) They are less likely to experience communication gaps between providers.
D) They often have multiple chronic conditions and complex care needs.

Answer 31

Correct answer: D) They often have multiple chronic conditions and complex care needs.

Question 32

Question 33:
Which of the following best represents a systems-level intervention to improve transitions of care?

A) Encouraging patients to create their own discharge plans
B) Implementing standardized handoff protocols and checklists
C) Limiting the number of medications prescribed at discharge
D) Reducing the frequency of follow-up appointments

Answer 32

Correct answer: B) Implementing standardized handoff protocols and checklists

Question 33

Scenario 1:
Mr. Johnson, a 78-year-old male with congestive heart failure (CHF) and diabetes, is being discharged from the hospital after a 5-day stay for an exacerbation of CHF. The hospital discharge team provided Mr. Johnson with verbal instructions to follow up with his primary care provider (PCP) in two weeks. The hospital failed to coordinate home health services, even though Mr. Johnson is reliant on assistance for daily activities.

Question:
What aspect of this discharge process is most likely to lead to a suboptimal transition of care?

A) Verbal discharge instructions
B) No home health services coordinated
C) Scheduling a PCP follow-up in two weeks
D) Hospital admission for CHF exacerbation

Answer 33

Correct answer: B) No home health services coordinated

Question 34

Scenario 2:
Ms. Lee, a 72-year-old woman with multiple chronic conditions, is transferred from the hospital to a skilled nursing facility (SNF) following a stroke. Upon arrival, the SNF staff receives incomplete medication information, leading to a delay in administering her prescribed medications.

Question:
Which of the following could have prevented this delay and ensured a smoother transition of care?

A) Providing verbal-only discharge instructions
B) Conducting a comprehensive medication reconciliation before discharge
C) Allowing the SNF to create a care plan without discharge information
D) Relying on the patient to manage their medications

Answer 34

Correct answer: B) Conducting a comprehensive medication reconciliation before discharge

Question 35

Mr. Garcia, a 68-year-old patient with chronic obstructive pulmonary disease (COPD), is discharged from the hospital after being treated for pneumonia. His discharge plan includes a new medication regimen, a follow-up appointment with his pulmonologist, and home oxygen therapy. However, the discharge team did not schedule his pulmonologist appointment or arrange for his oxygen delivery.

Question:
Which of the following best describes the error in Mr. Garcia’s transition of care?

A) Failure to conduct a proper discharge summary
B) Lack of comprehensive medication reconciliation
C) Incomplete coordination of follow-up care and medical equipment
D) Providing the patient with a discharge plan

Answer 35

Correct answer: C) Incomplete coordination of follow-up care and medical equipment

Question 36

Mrs. Thompson, a 75-year-old woman, is discharged from the hospital after surgery for a hip fracture. She lives alone and has limited mobility, and while her discharge instructions included home physical therapy, the services were not arranged. She also needs help with her activities of daily living (ADLs), such as bathing and dressing, which was not considered in the discharge plan.

Question:
What is the most significant risk factor for a suboptimal transition of care in Mrs. Thompson’s case?

A) Her age
B) Lack of home physical therapy arrangements
C) Hospitalization for a hip fracture
D) Surgery for her hip fracture

Answer 36

Correct answer: B) Lack of home physical therapy arrangements

Question 37

Mr. Patel, a 70-year-old patient with diabetes and hypertension, is discharged from the hospital after being treated for a severe foot ulcer. He was given both written and verbal discharge instructions to follow up with his wound care specialist in 10 days. However, no follow-up appointment was scheduled for him, and the discharge plan did not address his need for diabetes management post-discharge.

Question:
What would be the most appropriate intervention to prevent a suboptimal transition of care in Mr. Patel’s case?

A) Providing only written discharge instructions
B) Scheduling a follow-up appointment with the wound care specialist before discharge
C) Delaying his discharge until he can manage his diabetes independently
D) Assuming Mr. Patel will schedule his own follow-up appointment

Answer 37

Correct answer:* B) Scheduling a follow-up appointment with the wound care specialist before discharge

Question 38

Ms. Carter, a 74-year-old patient with hypertension and mild dementia, is transferred from the hospital to her home with a plan for home health visits. The discharge nurse does not clearly communicate the transfer plan to the home health agency, leading to a 3-day delay in home health services, during which Ms. Carter forgets to take her blood pressure medications.

Question:
Which of the following interventions would have improved Ms. Carter’s transition of care?

A) Waiting to contact the home health agency after discharge
B) Comprehensive communication with the home health agency prior to discharge
C) Relying on Ms. Carter to remember her medications
D) Not scheduling any home health services

Answer 38

Correct answer: B) Comprehensive communication with the home health agency prior to discharge

Question 39

Mr. Smith, an 80-year-old patient with congestive heart failure, was discharged from the hospital with instructions to monitor his weight daily and adjust his diuretic dose as needed. He was also instructed to follow up with his cardiologist within a week. However, no one followed up to ensure he understood the discharge instructions, and Mr. Smith did not schedule the cardiologist appointment.

Question:
What could have prevented a suboptimal transition of care for Mr. Smith?

A) Relying on the patient to monitor his weight
B) Providing only verbal discharge instructions
C) Scheduling a follow-up call to review discharge instructions and ensure the cardiologist appointment was scheduled
D) Assuming Mr. Smith would adjust his medications as instructed

Answer 39

Correct answer: C) Scheduling a follow-up call to review discharge instructions and ensure the cardiologist appointment was scheduled

Question 40

Mrs. Williams, a 72-year-old patient with diabetes and hypertension, is being discharged from the hospital after treatment for pneumonia. Her discharge plan includes home health services, including nursing care and physical therapy. However, the home health services were not coordinated before discharge, and no follow-up appointment with her primary care provider (PCP) was scheduled.

Question:
Which intervention could have prevented a suboptimal transition of care for Mrs. Williams?

A) Initiating discharge planning on the day of discharge
B) Coordinating home health services and scheduling a PCP follow-up before discharge
C) Providing Mrs. Williams with verbal instructions to arrange home health services herself
D) Discharging Mrs. Williams with no home health services but advising her to call her PCP

Answer 40

Correct answer: B) Coordinating home health services and scheduling a PCP follow-up before discharge

Question 41

Mr. Johnson, an 80-year-old patient with congestive heart failure, is transferred from the hospital to a skilled nursing facility (SNF). His care involves complex wound management and physical therapy. However, the SNF did not receive the discharge summary, leading to delays in administering his medications and coordinating his therapy.

Question:
Which of the following actions would have improved Mr. Johnson’s transition of care?

A) Discharging the patient without providing a written discharge summary
B) Timely transfer of the discharge summary and reconciliation of medications
C) Relying on the SNF to create their own care plan without hospital documentation
D) Expecting the patient’s family to communicate the hospital’s treatment plan to the SNF

Answer 41

Correct answer: B) Timely transfer of the discharge summary and reconciliation of medications

Question 42

Ms. Lee, a 70-year-old woman with COPD, is being discharged from the hospital. The discharge team fails to reconcile her preadmission medications with the new medications prescribed during her hospital stay. Ms. Lee mistakenly continues taking both her old and new medications after discharge, leading to adverse effects.

Question:
What step could have prevented Ms. Lee’s medication-related issue?

A) Providing her with a general medication list with no reconciliation
B) Conducting a thorough medication reconciliation at discharge
C) Giving Ms. Lee responsibility to manage her own medication list without review
D) Recommending she follow up with her PCP within two months

Answer 42

Correct answer: B) Conducting a thorough medication reconciliation at discharge

Question 43

Mr. Patel, a 68-year-old patient with diabetes, was discharged from the hospital with a new medication regimen and a plan for home health visits. The discharge team scheduled a follow-up appointment with his PCP within 14 days. However, the discharge instructions did not include the indication for each medication, and there was no plan to review Mr. Patel’s new medications with his home health nurse.

Question:
What would be the most appropriate step to ensure a safer transition of care for Mr. Patel?

A) Relying on Mr. Patel to understand and manage his new medications
B) Ensuring that the discharge summary includes the indication for each medication and coordinating medication review with his home health nurse
C) Delaying discharge until all his medications are discontinued
D) Instructing Mr. Patel to follow up with his PCP within two months instead of 14 days

Answer 43

Correct answer: B) Ensuring that the discharge summary includes the indication for each medication and coordinating medication review with his home health nurse

Question 44

Ms. Thomas, a 74-year-old woman with hypertension and mild dementia, is discharged to her home after a hospital stay. Her family caregiver is not informed about pending lab results, and no follow-up call is made to check on Ms. Thomas within the first two days of discharge. Three days later, Ms. Thomas returns to the hospital due to complications related to her condition.

Question:
Which of the following interventions could have improved Ms. Thomas’s transition of care?

A) Waiting for the caregiver to initiate contact with the hospital
B) Scheduling a follow-up call within two business days of discharge to review pending results and check on her condition
C) Providing discharge instructions to Ms. Thomas alone, without involving her caregiver
D) Recommending that Ms. Thomas schedule a follow-up appointment only if complications arise

Answer 44

Correct answer: B) Scheduling a follow-up call within two business days of discharge to review pending results and check on her condition

Question 45

Mr. Rivera, a 75-year-old man with multiple chronic conditions, is being discharged from the hospital. The care transition team contacts Mr. Rivera by phone within two business days of discharge and schedules a follow-up appointment with his PCP. However, the discharge summary sent to the PCP is incomplete and does not include test results pending at the time of discharge.

Question:
What aspect of Mr. Rivera’s transition of care requires improvement?

A) Scheduling a follow-up appointment
B) Providing verbal instructions to Mr. Rivera
C) Sending a complete discharge summary with pending test results to the PCP
D) Contacting Mr. Rivera within two business days of discharge

Answer 45

Correct answer: C) Sending a complete discharge summary with pending test results to the PCP

Question 46

Mrs. Brown, a 78-year-old patient with arthritis, is discharged from the hospital with new pain medications. Her discharge plan includes home health services and a follow-up visit with her primary care provider. However, her discharge instructions do not include a tapering schedule for the corticosteroids prescribed, and she continues to take the same dose after discharge.

Question:
What should have been included in Mrs. Brown’s discharge instructions to prevent a suboptimal transition of care?

A) A clear tapering schedule for the corticosteroids
B) An instruction to take her pain medications only as needed
C) A recommendation to follow up with her PCP in six months
D) Verbal instructions for her family caregiver

Answer 46

Correct answer: A) A clear tapering schedule for the corticosteroids

Question 47

Mr. Green, an 82-year-old man with diabetes, hypertension, and heart failure, is being discharged from the hospital to an acute rehab facility. The discharge team ensures that the rehab team has received the discharge summary and medication list, but the rehab team is not informed of the patient’s advanced directives or his family’s role in decision-making.

Question:
What information should have been communicated to the rehab facility to ensure an optimal transition?

A) The patient’s advanced directives and family’s role in decision-making
B) The patient’s age and length of stay in the hospital
C) Only the patient’s medication list
D) The patient’s diagnosis of diabetes

Answer 47

Correct answer:* A) The patient’s advanced directives and family’s role in decision-making

Question 48

Ms. Davis, an 81-year-old woman with COPD and osteoporosis, is discharged from the hospital with a plan to follow up with her pulmonologist and orthopedic specialist. However, neither of these appointments is scheduled for her, and Ms. Davis does not remember to schedule them herself.

Question:
What action could have improved the transition of care for Ms. Davis?

A) Relying on Ms. Davis to schedule her own follow-up appointments
B) Scheduling the follow-up appointments with her pulmonologist and orthopedic specialist before discharge
C) Providing her with a written discharge plan but no follow-up appointments
D) Discharging Ms. Davis without coordinating her specialist care

Answer 48

Correct answer: B) Scheduling the follow-up appointments with her pulmonologist and orthopedic specialist before discharge

Question 49

Mr. Lee, a 77-year-old patient with Parkinson’s disease, is discharged home after being treated for a urinary tract infection. His discharge medications include a PRN (as needed) order for an anti-anxiety medication, but no specific behavioral triggers are provided for when the medication should be used.

Question:
What should have been included in Mr. Lee’s discharge plan regarding his PRN medication?

A) A tapering schedule for the anti-anxiety medication
B) Specific behavioral triggers for using the PRN medication
C) A recommendation to use the medication daily
D) Instructions to discontinue the medication after one week

Answer 49

Correct answer: B) Specific behavioral triggers for using the PRN medication

Question 50

Ms. Wright, a 76-year-old woman with chronic kidney disease, is discharged from the hospital after treatment for a urinary tract infection. She is given new medications but no instructions on how they interact with her current medications. A week later, she is readmitted due to adverse drug interactions.

Question:
What step could have prevented Ms. Wright’s readmission?

A) Scheduling a follow-up appointment after two months
B) Providing detailed discharge instructions on potential drug interactions
C) Reducing the number of medications prescribed
D) Giving only verbal instructions about the new medications

Answer 50

Correct answer: B) Providing detailed discharge instructions on potential drug interactions

Question 51

Mr. Evans, a 79-year-old patient with dementia, is being discharged from the hospital to a skilled nursing facility (SNF) after treatment for pneumonia. His family caregiver receives the discharge summary but is not informed about the goals of care or his cognitive status. The SNF team experiences delays in creating a care plan due to the lack of information.

Question:
Which of the following should have been communicated to the SNF to ensure a smooth transition?

A) Mr. Evans’ age and weight
B) A comprehensive summary of his goals of care and cognitive status
C) A list of his daily activities
D) Instructions for his family caregiver to create the care plan

Answer 51

Correct answer: B) A comprehensive summary of his goals of care and cognitive status

Question 52

Ms. Baker, a 74-year-old patient with heart failure, is discharged with a new diuretic medication. Her discharge summary does not include instructions on the dosage or timing of the medication. She takes the medication incorrectly, leading to dehydration and readmission.

Question:
What key step in discharge planning was missed?

A) Informing the patient about potential side effects
B) Providing a detailed schedule for medication dosage and timing
C) Encouraging Ms. Baker to take the medication as she sees fit
D) Suggesting that she only take the medication if she feels unwell

Answer 52

Correct answer: B) Providing a detailed schedule for medication dosage and timing

Question 53

Scenario 14:
Mr. Garcia, a 72-year-old man with diabetes, is being discharged from the hospital after treatment for a diabetic foot ulcer. Although a follow-up appointment with his podiatrist is recommended, no appointment is scheduled. Mr. Garcia forgets to schedule the visit, and his condition worsens.

Question:
What would have improved the transition of care for Mr. Garcia?

A) Encouraging Mr. Garcia to schedule his own appointment
B) Scheduling the podiatrist appointment before discharge
C) Providing only verbal instructions about the importance of follow-up
D) Delaying discharge until his foot ulcer completely heals

Answer 53

Correct answer: B) Scheduling the podiatrist appointment before discharge

Question 54

Mrs. Thompson, an 83-year-old woman with osteoarthritis, is discharged from the hospital after knee replacement surgery. She is prescribed new pain medications, but the discharge team fails to reconcile her preadmission medications with the new ones. She continues taking both old and new medications, leading to a dangerous overdose.

Question:
What could have prevented Mrs. Thompson’s medication overdose?

A) Instructing her to stop taking all previous medications
B) Completing a thorough medication reconciliation before discharge
C) Providing verbal instructions only about her new medications
D) Delaying the prescription of pain medications until follow-up

Answer 54

Correct answer: B) Completing a thorough medication reconciliation before discharge

Question 55

Mr. Lewis, a 75-year-old patient with COPD, is discharged home after treatment for an acute exacerbation. He is sent home with an oxygen tank, but the discharge instructions do not include how to use it properly. As a result, Mr. Lewis misuses the oxygen, and his condition worsens.

Question:
Which of the following should have been included in Mr. Lewis’s discharge plan to prevent a poor outcome?

A) A recommendation to use the oxygen only when he feels short of breath
B) Detailed written and verbal instructions on how to properly use the oxygen tank
C) Instructions to discontinue oxygen therapy after one week
D) A follow-up appointment scheduled two months later

Answer 55

Correct answer: B) Detailed written and verbal instructions on how to properly use the oxygen tank

Question 56

Mrs. Davis, a 78-year-old patient with hypertension and depression, is being discharged from the hospital to her home. Her family caregiver is not involved in the discharge planning, and no follow-up plan is provided for her mental health care. A week after discharge, Mrs. Davis experiences a mental health crisis and is readmitted.

Question:
Which intervention could have improved Mrs. Davis’s transition of care?

A) Providing only verbal instructions to Mrs. Davis without caregiver involvement
B) Including her family caregiver in the discharge planning process and arranging mental health follow-up
C) Recommending that Mrs. Davis schedule her own mental health care follow-up
D) Discharging Mrs. Davis without a plan for her depression management

Answer 56

Correct answer: B) Including her family caregiver in the discharge planning process and arranging mental health follow-up

Question 57

Mr. Taylor, a 79-year-old patient with a recent stroke, is being transferred to a long-term acute care facility (LTAC) for rehabilitation. His discharge summary does not include the results of a pending MRI or information on his long-term care goals. As a result, the LTAC team struggles to create an appropriate care plan.

Question:
What key information should have been included in Mr. Taylor’s discharge summary?

A) His age and length of hospital stay
B) The pending MRI results and his long-term care goals
C) A list of his daily activities
D) Only his medications at the time of discharge

Answer 57

Correct answer: B) The pending MRI results and his long-term care goals

Question 58

Ms. Carter, an 81-year-old woman with congestive heart failure, is discharged to a skilled nursing facility (SNF) after hospitalization. The hospital discharge summary is incomplete, and the SNF receives no information about her cognitive status or baseline functional abilities. This leads to delays in her care planning.

Question:
What information should have been included in Ms. Carter’s discharge summary to improve her transition of care?

A) Information about her cognitive status and baseline functional abilities
B) Only a list of her current medications
C) The date of her discharge
D) Instructions for the SNF to create a care plan from scratch

Answer 58

Correct answer: A) Information about her cognitive status and baseline functional abilities

Question 59

Mr. Brown, a 70-year-old patient with diabetes and peripheral vascular disease, is discharged from the hospital after treatment for an infected foot wound. The discharge team fails to coordinate home health care for wound management. As a result, his wound worsens, and he is readmitted.

Question:
What could have prevented Mr. Brown’s readmission?

A) Scheduling a follow-up appointment with his PCP two months after discharge
B) Coordinating home health care services for wound management before discharge
C) Providing Mr. Brown with verbal instructions only about wound care
D) Encouraging Mr. Brown to manage his wound care independently

Answer 59

Correct answer: B) Coordinating home health care services for wound management before discharge

Question 60

Ms. Greene, a 78-year-old woman with osteoporosis, is discharged home after a hip fracture. Her discharge summary includes a list of medications, but it lacks any indication of why each medication is prescribed. Ms. Greene becomes confused about her medications and stops taking them.

Question:
What should have been included in Ms. Greene’s discharge plan to prevent confusion?

A) A list of medications without any explanation
B) Indications for each medication to ensure Ms. Greene understands their purpose
C) Verbal instructions only on how to take the medications
D) An instruction for Ms. Greene to follow up with her PCP in two months

Answer 60

Correct answer: B) Indications for each medication to ensure Ms. Greene understands their purpose

Question 61

Mr. Hughes, a 76-year-old patient with diabetes, is discharged from the hospital after a hypoglycemic episode. His discharge plan includes follow-up care, but no contact was made with his PCP. Mr. Hughes is readmitted with another hypoglycemic episode a week later.

Question:
Which action could have improved Mr. Hughes’s transition of care?

A) Delaying discharge until his blood sugar was stabilized
B) Contacting his PCP before discharge to arrange follow-up care
C) Providing only verbal discharge instructions
D) Allowing Mr. Hughes to follow up with his PCP at his convenience

Answer 61

Correct answer: B) Contacting his PCP before discharge to arrange follow-up care

Question 62

Mrs. Johnson, an 85-year-old patient with dementia, is discharged to her daughter’s home after hospitalization for pneumonia. The discharge team does not provide her daughter with information about the signs of pneumonia recurrence or how to manage her mother’s dementia. Mrs. Johnson is readmitted within 10 days.

Question:
What should have been included in the discharge plan to prevent Mrs. Johnson’s readmission?

A) A list of Mrs. Johnson’s medications
B) Clear instructions for her daughter on the signs of pneumonia recurrence and dementia management
C) Instructions for Mrs. Johnson to follow up with her PCP
D) Verbal instructions for Mrs. Johnson without caregiver involvement

Answer 62

Correct answer: B) Clear instructions for her daughter on the signs of pneumonia recurrence and
dementia management

Question 63

Mr. Patel, a 68-year-old patient with chronic obstructive pulmonary disease (COPD), is discharged after treatment for an acute exacerbation. His discharge summary lacks detailed information on how to adjust his inhaler use during flare-ups. Mr. Patel experiences another exacerbation and is readmitted within a week.

Question:
What key information was missing from Mr. Patel’s discharge instructions?

A) Instructions on how to adjust his inhaler use during flare-ups
B) A recommendation to follow up with his PCP after two months
C) Verbal instructions to avoid strenuous activity
D) A suggestion to only use his inhaler when feeling very short of breath

Answer 63

Correct answer: A) Instructions on how to adjust his inhaler use during flare-ups

Question 64

Ms. Lee, a 77-year-old woman with Parkinson’s disease, is being discharged to a skilled nursing facility (SNF) after hospitalization. The discharge team does not inform the SNF about her advanced directives or her family’s involvement in decision-making. This leads to confusion about her care goals at the SNF.

Question:
What could have prevented confusion about Ms. Lee’s care at the SNF?

A) Providing information only about her medications
B) Including her advanced directives and family’s role in decision-making in the discharge summary
C) Recommending the SNF create its own care plan based on their initial assessment
D) Encouraging the family to call the SNF after discharge

Answer 64

Correct answer: B) Including her advanced directives and family’s role in decision-making in the discharge summary

Question 65

Mr. Rogers, a 79-year-old patient with diabetes, is discharged home after treatment for an infected leg wound. The discharge team fails to coordinate home health visits for wound care, and Mr. Rogers is readmitted after his wound worsens.

Question:
What could have prevented Mr. Rogers’s readmission?

A) Scheduling his follow-up with the PCP in three months
B) Coordinating home health visits for wound care before discharge
C) Instructing Mr. Rogers to manage his wound care independently
D) Recommending that Mr. Rogers visit the emergency department if the wound worsens

Answer 65

Correct answer: B) Coordinating home health visits for wound care before discharge

Question 66

Mr. Jones, a 73-year-old patient with hypertension and chronic kidney disease, is discharged from the hospital with new blood pressure medications. His discharge summary does not include any information about how to adjust his medication if his blood pressure drops too low. A week later, he is readmitted with hypotension.

Question:
What could have prevented Mr. Jones’s readmission?

A) Delaying his discharge until his blood pressure stabilizes
B) Including clear instructions on how to adjust his medication if his blood pressure drops
C) Providing verbal instructions to adjust his medication at his discretion
D) Scheduling a follow-up appointment for six months after discharge

Answer 66

Correct answer:* B) Including clear instructions on how to adjust his medication if his blood pressure drops

Question 67

Mrs. Smith, an 82-year-old woman with Alzheimer’s disease, is discharged home after treatment for a urinary tract infection. The discharge team does not ensure that her caregiver receives proper training on how to manage her condition or how to recognize symptoms of a recurrence. Mrs. Smith’s condition worsens, and she is readmitted.

Question:
What could have improved the transition of care for Mrs. Smith?

A) Providing only verbal instructions to Mrs. Smith
B) Ensuring that her caregiver received training on managing her condition and recognizing symptoms of recurrence
C) Recommending that Mrs. Smith follow up with her PCP without caregiver involvement
D) Suggesting that the caregiver contact the hospital if symptoms worsen

Answer 67

Correct answer: B) Ensuring that her caregiver received training on managing her condition and recognizing symptoms of recurrence

Question 68

Mr. Adams, a 69-year-old man with type 2 diabetes, is discharged from the hospital after treatment for an infection. He is given a new insulin regimen but no instructions on how to adjust his dosage based on his blood glucose readings. He experiences a hypoglycemic episode two days later and is readmitted.

Question:
What step was missed in Mr. Adams’s discharge plan?

A) Scheduling a follow-up appointment with his endocrinologist
B) Providing clear instructions on how to adjust his insulin dosage based on blood glucose levels
C) Delaying discharge until his blood glucose levels are stable
D) Recommending that he follow up with his PCP in one month

Answer 68

Correct answer: B) Providing clear instructions on how to adjust his insulin dosage based on blood glucose levels

Question 69

Ms. Davis, a 74-year-old woman with chronic obstructive pulmonary disease (COPD), is discharged from the hospital after a COPD exacerbation. Her discharge instructions include her medications but do not specify when to use her rescue inhaler. She is readmitted with worsening symptoms within a week.

Question:
What could have prevented Ms. Davis’s readmission?

A) Telling her to use the rescue inhaler only if she feels very unwell
B) Including clear instructions on when to use her rescue inhaler during an exacerbation
C) Advising her to stop using all medications until her symptoms worsen
D) Providing verbal instructions about her medications without a written plan

Answer 69

Correct answer: B) Including clear instructions on when to use her rescue inhaler during an exacerbation

Question 70

Mr. Lopez, a 72-year-old patient with heart failure, is discharged from the hospital with instructions to monitor his weight daily and follow a low-sodium diet. However, no follow-up visit with his cardiologist is scheduled, and his condition worsens within 10 days.

Question:
What step could have ensured a safer transition of care for Mr. Lopez?

A) Relying on Mr. Lopez to monitor his own symptoms
B) Scheduling a follow-up visit with his cardiologist before discharge
C) Providing only verbal instructions about his diet and weight monitoring
D) Suggesting Mr. Lopez visit the emergency department if his symptoms worsen

Answer 70

Correct answer:* B) Scheduling a follow-up visit with his cardiologist before discharge

Question 71

What is the primary goal of discharge planning?

A) To reduce hospital stay lengths
B) To prevent hospital readmissions and ensure continuity of care
C) To provide patients with only verbal instructions about medications
D) To limit the number of follow-up appointments

Answer 71

Correct answer:* B) To prevent hospital readmissions and ensure continuity of care

Question 72

Which of the following is a common risk factor for suboptimal transitions of care?

A) Comprehensive medication reconciliation
B) Lack of follow-up care coordination
C) Providing clear discharge instructions
D) Early initiation of discharge planning

Answer 72

Correct answer: B) Lack of follow-up care coordination

Question 73

Which of the following is a key component of the Community-Based Care Transitions Program (CCTP)?

A) Increasing patient hospital stay lengths
B) Coordinating care between the hospital and community-based services to prevent readmissions
C) Reducing the role of primary care providers in post-discharge care
D) Encouraging patients to manage their own discharge plan without assistance

Answer 73

Correct answer: B) Coordinating care between the hospital and community-based services to prevent readmissions

Question 74

Which of the following is critical to improving transitions of care for older adults?

A) Initiating discharge planning on the day of discharge
B) Contacting the patient’s primary care provider before discharge to coordinate follow-up care
C) Providing only verbal discharge instructions
D) Scheduling a follow-up appointment months after discharge

Answer 74

Correct B) Contacting the patient’s primary care provider before discharge to coordinate follow-up care

Question 75

What is one benefit of early discharge planning?

A) It reduces the need for follow-up care
B) It ensures a smoother transition and reduces the risk of readmission
C) It eliminates the need for medication reconciliation
D) It allows the patient to schedule their own follow-up appointments

Answer 75

Correct answer:* B) It ensures a smoother transition and reduces the risk of readmission

Question 76

Which of the following should be included in a discharge summary to ensure optimal transitions of care?

A) The patient’s age and weight
B) A detailed list of all medications, including any changes made during hospitalization
C) Only verbal instructions for the patient’s family
D) A recommendation to follow up with the PCP at the patient’s discretion

Answer 76

Correct answer: B) A detailed list of all medications, including any changes made during hospitalization

Question 77

What step can significantly reduce medication errors during transitions of care?

A) Relying on the patient to manage their own medication changes
B) Completing a comprehensive medication reconciliation at admission and discharge
C) Providing only verbal instructions about medication changes
D) Allowing the patient to continue taking all preadmission medications

Answer 77

Correct answer:* B) Completing a comprehensive medication reconciliation at admission and discharge

Question 78

Which of the following best describes a systems-level intervention to improve transitions of care?

A) Encouraging patients to create their own discharge plans
B) Implementing standardized handoff protocols and checklists for all discharges
C) Reducing the number of medications prescribed at discharge
D) Limiting communication between healthcare providers during transitions

Answer 78

Correct answer:* B) Implementing standardized handoff protocols and checklists for all discharges

Question 79

Why is it important to schedule follow-up appointments for patients before discharge?

A) It reduces the likelihood that patients will miss their follow-up care
B) It allows the patient to decide if follow-up care is necessary
C) It decreases hospital costs
D) It eliminates the need for other discharge instructions

Answer 79

Correct answer: A) It reduces the likelihood that patients will miss their follow-up care

Question 80

Which patient is most at risk for a suboptimal transition of care?

A) A patient with stable health conditions and strong family support
B) A patient with multiple chronic conditions and no clear follow-up care plan
C) A patient with a well-coordinated discharge plan that includes follow-up appointments
D) A patient with scheduled home health visits and a clear medication list

Answer 80

Correct answer: B) A patient with multiple chronic conditions and no clear follow-up care plan

Question 81

Which of the following is a primary reason older adults are at a higher risk for suboptimal transitions of care?

A) They are more likely to understand discharge instructions
B) They typically require fewer medications
C) They often have multiple chronic conditions and complex care needs
D) They experience fewer transitions between care settings

Answer 81

Correct answer: C) They often have multiple chronic conditions and complex care needs

Question 82

What is a key benefit of the Transitional Care Management (TCM) Payment Codes introduced by CMS?

A) Reducing the cost of inpatient care
B) Incentivizing hospitals to discharge patients early
C) Supporting providers in ensuring post-discharge follow-up care within 30 days
D) Limiting the number of medications prescribed to patients

Answer 82

Correct answer: C) Supporting providers in ensuring post-discharge follow-up care within 30 days

Question 83

Which of the following actions can help reduce 30-day hospital readmissions?

A) Providing only verbal instructions to patients upon discharge
B) Conducting a follow-up phone call within two business days of discharge
C) Discharging patients without scheduling follow-up appointments
D) Recommending patients schedule their follow-up visits after they leave the hospital

Answer 83

Correct answer: B) Conducting a follow-up phone call within two business days of discharge

Question 84

What information is essential to include when discharging a patient to another care setting, such as a nursing home?

A) Only the patient’s age and diagnosis
B) A clear summary of the patient’s care goals, functional status, and pending test results
C) The patient’s discharge date only
D) Instructions for the new care setting to perform their own assessments without prior information

Answer 84

Correct answer: B) A clear summary of the patient’s care goals, functional status, and pending test results

Question 85

Which of the following interventions can help improve transitions of care for older adults?

A) Providing instructions only to the patient, even if they have cognitive impairments
B) Ensuring the caregiver is involved in the discharge planning process
C) Relying on the patient to arrange follow-up care without assistance
D) Avoiding the involvement of family members in discharge planning

Answer 85

Correct answer: B) Ensuring the caregiver is involved in the discharge planning process

Question 86

Which of the following is a recommended action for managing medications during discharge to prevent adverse events?

A) Telling patients to continue all medications they were taking before admission
B) Reconciling preadmission and hospital medications to ensure the correct regimen is continued
C) Discontinuing all medications prescribed during the hospital stay
D) Providing patients with a general medication list without explaining changes

Answer 86

Correct answer:* B) Reconciling preadmission and hospital medications to ensure the correct regimen is continued

Question 87

Which of the following is an example of an optimal transition of care?

A) Discharging a patient with a clear follow-up plan and detailed discharge summary
B) Discharging a patient without ensuring home health services are coordinated
C) Relying on the patient to manage their own medications after discharge
D) Avoiding follow-up communication with the patient’s primary care provider

Answer 87

Correct answer: A) Discharging a patient with a clear follow-up plan and detailed discharge summary

Question 87

What role does follow-up care play in transitions of care?

A) It reduces the need for medication reconciliation
B) It ensures continuity of care and reduces the risk of hospital readmission
C) It eliminates the need for discharge instructions
D) It limits communication between care providers

Answer 87

Correct answer: B) It ensures continuity of care and reduces the risk of hospital readmission

Question 88

What is the purpose of a comprehensive medication review during discharge planning?

A) To provide patients with a list of new medications only
B) To identify discrepancies between preadmission and post-hospital medications and prevent medication errors
C) To reduce the number of medications a patient takes
D) To delay discharge until all medications are reconciled

Answer 88

Correct answer: B) To identify discrepancies between preadmission and post-hospital medications and prevent medication errors

Question 89

Which of the following is a common reason for suboptimal transitions of care?

A) Timely communication of discharge information to the next care setting
B) Failure to schedule follow-up appointments before discharge
C) Including caregivers in the discharge planning process
D) Comprehensive medication reconciliation before discharge

Answer 89

Correct answer: B) Failure to schedule follow-up appointments before discharge