VERIFIED ANSWERS | GRADED A+| PASS ON FIRST ATTEMPT |
Elements of CCTM - 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 - 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 - 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
1
,-Engage all team members in care coordination
The logic model and CCTM - 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 - 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 - 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
2
, 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 - 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 - 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 hand-off 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;
3
Elements of CCTM - 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 - 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 - 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
1
,-Engage all team members in care coordination
The logic model and CCTM - 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 - 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 - 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
2
, 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 - 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 - 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 hand-off 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;
3
