NURS 242 Exam 3 (with Accurate Answers)

Care Coordination correct answers with focus on children with special health care needs, care coordination was presented as a process connecting both services and resources and involving patients, providers, and families, with the goals of optimal health care and optimal patient outcomes Scope of Care Coordination correct answers Efficient - Inefficient Efficient: well-coordinated care across multiple health care entities and involving multiple health care professionals Inefficient: poor coordination of care, a complete lack or care coordination Inter-organizational and Interprofessional Team Including the Patient correct answers -Existing care coordination structure, guidelines, and organizational links -Team based and interprofessional -Inclusive of patient and patient's support system -Trusting interaction among team members -Shared and appreciated understanding of roles -Clinical integration and interdependence -Central point of contact (a person, partnership of providers, agency, or organization) responsible for continuity of care and management of all other attributes (nursing identified as most common clinical discipline as designated care coordinator, followed by social workers and pharmacists) Communication and Information Exchange correct answers -Information exchange across services and team members before and after each interaction -Standardized communication template of a minimal set of care data elements accessible to all team members, particularly during transitions of care -Electronic record system to allow team members timely access to plan of care and data at all points in time with efficient and effective integration of patient information, laboratory data, imaging results, referrals, medications, social and community services, and self-management support -Built-in support for quality improvement and safety, evidence-based decision support tools, provider alerts, and patient reminders -Comprehensive in-hospital planning, home-based visits, and telephone follow-up to ensure continuity over transitions in care A proactive plan of care with goals correct answers -Created, documented, executed, and updated with every patient -Comprehensive including community and nonclinical services with health care services that incorporate the patient's needs, preferences, and resources to achieve the patient's goals -Developed and shared across providers and patient's support system -Revised as needed -Patients most likely to benefit identified -Patient-centered and family-focused