COMPLEX TRANSITIONAL NURSING
CARE NURB390 EXAM 3 UPDATED
EXAM SCRIPT 2026 TEST PAPER
QUESTIONS AND SOLUTIONS
GRADED A+
◉ Continuity of Care.
Answer: An interdisciplinary process that includes clients and
significant others in the development of a coordinated plan of care. This
process facilitates the client's transition between settings, based on
changing needs and available resources
◉ Case Management.
Answer: A system of health care delivery designed to facilitate
achievement of expected patient outcomes within an appropriate length
of stay.
◉ Why Understand the Continuum?.
Answer: Health care is increasingly
Complex
Fragmented - the ACA will not change this much
Benefit and Resource Driven
Expensive
AND...
,Payors and Regulators require demonstrated evidence of coordination of
care across the continuum
◉ What's Driving Continuum Complexity?.
Answer: Social/demographic
Economic
Medical/Technologic
Nursing
◉ Multiple and Converging Social and Demographic Forces.
Answer: Rising life expectancy:
1900 average US life span 47.3
2012 average US life span 78.8
81.2 Females/76.4 Males
Older population over 65 most rapidly growing group
15% still working at age 65
Falling US Birthrate:
Fewer workers supporting more retired people
Over 65: 12% of population; 2050: 21% of population
◉ Points to Ponder.
Answer: 26% of population >65 have a major chronic condition
Population >75 have an average of 3 chronic conditions
, 40% of the population >80 has Alzheimers - 8 million by 2020
Elderly (14% of the population) use 25% of the MD visits, 50% of the
hospital days, 70% of the home health visits and 85% of the SNF beds
Advances in chronic disease management: longer lives with more
diseases
◉ Background.
Answer: Hospitalization is a segment of health care continuum
>10 million discharges/yr
Quicker and sicker discharges of older and frailer patients
Joint Commission guidelines for multi-disciplinary discharge planning
as component of high-quality care
Poor hospital reimbursement if pt no longer acute
◉ Other Social Forces.
Answer: 16million type II diabetics - many are adolescent and young
adults
Rising obesity epidemic - 25% of population obese, 66% overweight
(CDC, 2005)
Poor national health behaviors
20% of us still smoke, 20% drink alcohol excessively
30% exercise - at all
46+ million uninsured: 20 % of the population, with many more
underinsured
Shift to part time and temporary work
CARE NURB390 EXAM 3 UPDATED
EXAM SCRIPT 2026 TEST PAPER
QUESTIONS AND SOLUTIONS
GRADED A+
◉ Continuity of Care.
Answer: An interdisciplinary process that includes clients and
significant others in the development of a coordinated plan of care. This
process facilitates the client's transition between settings, based on
changing needs and available resources
◉ Case Management.
Answer: A system of health care delivery designed to facilitate
achievement of expected patient outcomes within an appropriate length
of stay.
◉ Why Understand the Continuum?.
Answer: Health care is increasingly
Complex
Fragmented - the ACA will not change this much
Benefit and Resource Driven
Expensive
AND...
,Payors and Regulators require demonstrated evidence of coordination of
care across the continuum
◉ What's Driving Continuum Complexity?.
Answer: Social/demographic
Economic
Medical/Technologic
Nursing
◉ Multiple and Converging Social and Demographic Forces.
Answer: Rising life expectancy:
1900 average US life span 47.3
2012 average US life span 78.8
81.2 Females/76.4 Males
Older population over 65 most rapidly growing group
15% still working at age 65
Falling US Birthrate:
Fewer workers supporting more retired people
Over 65: 12% of population; 2050: 21% of population
◉ Points to Ponder.
Answer: 26% of population >65 have a major chronic condition
Population >75 have an average of 3 chronic conditions
, 40% of the population >80 has Alzheimers - 8 million by 2020
Elderly (14% of the population) use 25% of the MD visits, 50% of the
hospital days, 70% of the home health visits and 85% of the SNF beds
Advances in chronic disease management: longer lives with more
diseases
◉ Background.
Answer: Hospitalization is a segment of health care continuum
>10 million discharges/yr
Quicker and sicker discharges of older and frailer patients
Joint Commission guidelines for multi-disciplinary discharge planning
as component of high-quality care
Poor hospital reimbursement if pt no longer acute
◉ Other Social Forces.
Answer: 16million type II diabetics - many are adolescent and young
adults
Rising obesity epidemic - 25% of population obese, 66% overweight
(CDC, 2005)
Poor national health behaviors
20% of us still smoke, 20% drink alcohol excessively
30% exercise - at all
46+ million uninsured: 20 % of the population, with many more
underinsured
Shift to part time and temporary work
