Ambulatory Care Exam 1 Questions with Correct Answers
Question 1:
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
Question 2:
Care coordination
Answer:
Need high quality referral or transition Should be timelySafe: 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
Question 3:
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
Answer:
6 principles of CCTM Nusing
Question 4:
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
logicComponents:Inputs: resources that go into the program Activities: actual events or actions
that take place Products: direct tangible output of program activities
,Question 5:
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
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Question 6:
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 changesMaintenance - have made changes and working to prevent relapse
Termination - not always recognized as a stage
Question 7:
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 importantCommunity - pathological social conditions Treat
community and other sources Industrialization/depression-Lack of coordination, resources,
accessChallenges - communicable disease, stresses of immigration and SES disparity Cost of
healthcare unsustainableFiscal caps pushed large volumes of services to outpatient Acuity of
patient care escalated in ambulatory areas
, Question 8:
Affordable Care Act
Answer:
In 2011, the law provided for free preventive care for seniors such as annual wellness visits and
personalized prevention plansCommunity Care Transitions program for at risk Senior Adults,
preventing ED visits and hospital readmissionsincreased reimbursement for primary careState
sanctioned Patient Centered Medical HomesPhysician reimbursement changing from
Fee-for-Service to Value Based Care models
Question 9:
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 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
Question 10:
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;
-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.
Question 1:
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
Question 2:
Care coordination
Answer:
Need high quality referral or transition Should be timelySafe: 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
Question 3:
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
Answer:
6 principles of CCTM Nusing
Question 4:
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
logicComponents:Inputs: resources that go into the program Activities: actual events or actions
that take place Products: direct tangible output of program activities
,Question 5:
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
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Outcomes: impact of the program; the sequence of effects triggered by the program, often
expressed in terms of short term, intermediate, and distal outcomes
Question 6:
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 changesMaintenance - have made changes and working to prevent relapse
Termination - not always recognized as a stage
Question 7:
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 importantCommunity - pathological social conditions Treat
community and other sources Industrialization/depression-Lack of coordination, resources,
accessChallenges - communicable disease, stresses of immigration and SES disparity Cost of
healthcare unsustainableFiscal caps pushed large volumes of services to outpatient Acuity of
patient care escalated in ambulatory areas
, Question 8:
Affordable Care Act
Answer:
In 2011, the law provided for free preventive care for seniors such as annual wellness visits and
personalized prevention plansCommunity Care Transitions program for at risk Senior Adults,
preventing ED visits and hospital readmissionsincreased reimbursement for primary careState
sanctioned Patient Centered Medical HomesPhysician reimbursement changing from
Fee-for-Service to Value Based Care models
Question 9:
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 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
Question 10:
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;
-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.
