COMPLETE QUESTIONS AND ANSWERS FOR AMBULATORY CARE EXAM 1

COMPLETE QUESTIONS AND ANSWERS FOR AMBULATORY CARE EXAM 1 Elements of CCTM - CORRECT ANSWER--Assuming accountability -Providing patient support -Building relationships and agreements among providers that lead to shared expectations for communication and care -Developing connectivity via electronic or other information pathways that encourage timely and effective information flow between Care coordination - CORRECT ANSWER-Need high quality referral or transition Should be timely Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors. Effective: referrals and transitions are based on scientific knowledge Patient centered efficient Equitable 6 principles of CCTM Nusing - CORRECT ANSWER-These six principles provide a basis for establishing an informed and collaborative care coordination process that includes all staff, key stakeholders, and nurse leaders across the continuum of care: -Know how care is coordinated in your setting -Know who is providing care -Establish relationships with multiple entities and individuals who can work together to improve care coordination and transition management systems -Know the value of technology, its impact on workflow, and the roles of care coordination team members -Engage the patient and family -Engage all team members in care coordination The logic model and CCTM - CORRECT ANSWER-The Logic Model depicts program outcomes, how the program is supposed to accomplish these outcomes and what is the basis (logic) for these expectations. Links program inputs (resources) and activities to the program products and outcomes while communicating the logic Components: Inputs: resources that go into the program Activities: actual events or actions that take place Products: direct tangible output of program activities Outcomes: impact of the program; the sequence of effects triggered by the program, often expressed in terms of short term, intermediate, and distal outcomes Stages of change model - CORRECT ANSWER-Stages: ◦Precontemplation - no intention to change in the next 6 months ◦Contemplation - intend to change in the next 6 months ◦Preparation - intend to take action in the immediate future ◦Action - observable changes ◦Maintenance - have made changes and working to prevent relapse ◦Termination - not always recognized as a stage Public health nursing - CORRECT ANSWER-Lillian Wald visiting nurses - decision that need public health nurses and integrate courses or have it be post grad -Education is important Community - pathological social conditions Treat community and other sources Industrialization/depression -Lack of coordination, resources, access Challenges - communicable disease, stresses of immigration and SES disparity Cost of healthcare unsustainable Fiscal caps pushed large volumes of services to outpatient Acuity of patient care escalated in ambulatory areas Affordable Care Act - CORRECT ANSWER-In 2011, the law provided for free preventive care for seniors such as annual wellness visits and personalized prevention plans Community Care Transitions program for at risk Senior Adults, preventing ED visits and hospital readmissions increased reimbursement for primary care State sanctioned Patient Centered Medical Homes Physician reimbursement changing from Fee-for-Service to Value Based Care models Misconceptions of ambulatory care nursing - CORRECT ANSWER--a misconception that the acute care setting is the point of access for individuals requiring care coordination and transition management, when in fact the ambulatory care setting is the point of access; -a misconception that care transitions originate with a hospitalization rather than recognizing the multiple care transitions occurring among diverse ambulatory care settings; -a misconception that a measure of care coordination and transition management is handing patients written instructions prior to discharge, a single intervention of a handoff but not a measure of performance of care being coordinated or the transition being managed; -a misconception that care coordination and transition management are discrete points of communication rather than a continuous conversation with ongoing communication; -a misconception that individuals with complex health care needs are equipped with self-management skills and decision-making skills to know what to do when their condition worsens or they develop a complication -a misconception that individuals with complex health care needs seek care in traditional primary care settings, when diverse ambulatory settings are serving vulnerable populations including uninsured, Medicaid, and geographically and economically disadvantaged. 3 General contexts of ambulatory care nurses: - CORRECT ANSWER-- episodic/preventative care -chronic disease management -practice operations Episodic/preventative care - CORRECT ANSWER--Teletriage -Medication recon -Promote adherence to treatment -HPI/patient health status - flag key findings for prioritization Chronic disease management - CORRECT ANSWER--Telecommunication -Discharge strategies - better education -Early identification of sx Practice Operations - CORRECT ANSWER--Guide teletriage -QI Data analysis practice leadership -Prioritizing patient appointment access and service coordination RN skills were viewed as vital to manage patient flow and capacity, enhance same day care needs, and accommodate after hours scheduling -Trained and supervised LPNs and MAs -Directed community based teams -Managed patient navigation centers -Providing continuity when PCPs were unavailable Position statement for ambulatory nurses - CORRECT ANSWER-•RNs enhance patient safety and the quality and effectiveness of care delivery and are thus essential and irreplaceable in the provision of patient care services in the ambulatory setting.