D046 Intro to Care Coordination Study Guide Graded A 2024

A patient arrives at your organization and needs specific care. Recently, your organization signed an agreement with a university health system to allow for telehealth assessment and identification of potential treatment options. As the coordinator for this patient, what would be the next step to determine if this is a good solution? - Contact the leadership team and the telehealth informatics specialist to identify whether everything is in place for this patient to receive care through this association. Telehealth initiatives have associated a lot of organizations with university and other larger health systems to facilitate a collaborative practice for care delivery. A patient is ready to go home, and the family has expressed concern about the patient being on her own during the day. The patient is unable to complete full activities of daily living due to a recent injury. Is there something that the coordination team can recommend for provision of lunch or dinner? - Recommend that the family contact the local Meals on Wheels program, so they can ensure the patient has access to food and drink during the day. The patient has some activities for daily living but is not able to complete all activities. Since the concern is around food during the day, the coordinator identified a service that provides free or reduced delivery of hot meals one time a day. Use of this service also provides reassurance for the family that someone has checked on the patient that day. The care team has determined that to reverse behaviors of smoking, a patient and family should seek ongoing support. What recommendations would the care coordinator make? - The care coordinator recommends current community outreach programs available and assists the patient and family in deciding which option will meet their needs. The care coordinator should have a list of partners in the community who can assist patients and families, encouraging compliance and promoting health wellness. Provide an example of the clinic-clinician patient relationship. - Examples of the clinic-clinician patient relationship include trust between the clinician and patient, shared decision-making, and mechanisms for mutual support of patient self-management. Provide an example of the clinic-clinician-community resource relationship. - Examples of the clinic-clinician-community resource relationship include the level of interrelationship along Himmelman's continuum for collaborative processes, formal mechanisms for referrals, and effective mechanisms for feedback from community resource to clinic. Provide an example of the patient-community resource relationship. - Examples of the patient-community resource relationship include patients' perception and trust of the community resource, formal mechanisms for referrals, and effective communication between patient and community resource. Using health technology to gather patient-specific data in their electronic health record, how could the care coordination team focus care on an individual patient? - Using the data collected provides a collection of problems and diagnosis-related groups (DRGs) that can help the care team determine discharge needs. Review of demographic data can provide information after validation that the information is correct during the assessment phase of contact with the patient and family. The electronic health record is a tool used by the coordination team and others to gather information on what is going on with the patient, by providing information on both the current situation and the medical history. It can also include advance directive information for the future. Where should the documentation of the care plan be recorded? - In the care planning module of the electronic health record The electronic health record is where all the care team members have access to the record of the patient, and it is the official health record for that patient. A pregnant client is living in the wilds of Alaska. She is not considered to be high risk and there is no reason for her to stay close to town since a frontier midwife is available to travel to her home every month. What would the care coordinator recommend for the client? - Satellite telecommunications device A satellite phone is recommended to ensure that if any questions arise when the midwife is not available, the client can call for help. Which statement describes how a healthcare coordinator improves the quality of care delivered in the community? - Serves as a bridge between patients, families, and other health care providers. Care coordinators organize care provided by multiple providers that may not have the ability or means to communicate with each other. Coordinating care improves disease management and patient compliance, offers resources, and removes barriers. A care coordinator collaborates with health care providers to ensure that a patient with a chronic health problem receives appropriate care, avoids hospitalization, and attends follow-up visits as scheduled. For which reason should the healthcare coordinator use health information technology (HIT) to improve a patient's care? - It improves communication between clinicians and inpatient and outpatient healthcare settings. HIT improves communication between multiple clinicians and clinical sites by improving access to the patient's medical and medication history, plan of care, referral history, and support services. A care coordinator is scheduled to meet with adolescents and adult patients in a community clinic. Which action could a healthcare coordinator take to demonstrates how care coordination improves in disease management? - Meet with the school nurse to review the action plans for students with asthma. Care coordination interventions for patients with chronic diseases effectively link outreach, support services, education and guidance. Meeting with the school nurse to review the action plans for students with asthma ensures compliance with medication use and administration in a location convenient for the patient and care providers. What are the outcome goals of the Ambulatory Integration of Medical and Social (AIMS) model? - To obtain patient engagement, identify a best practice care model, manage cases as a team, and identify the potential ongoing needs of the patient and family to maintain optimal health The AIMS model goals are patient engagement, care plan development, case management, and ongoing care as needed. What occurs during the patient engagement and assessment phases of the AIMS model? - The patient engagement and assessment phases occur during the initial introduction and detailed interview. This allows for the care coordinator and patient to build a trusting relationship and identify the goals and outcomes for care delivery, identify what part each team member will play in the ongoing care team, and identify any concerns that need to be addressed to improve the potential for meetings the goals of care delivery. The introduction of the care coordinator to the care planning process, review of the aims of the team to facilitate optimal health, and incorporation of whatever considerations need to be addressed are vital to a quality outcome. The client and family should be actively engaged in the process. What is the goal for the case management phase in the AIMS model? - The goals are about managing the care plan and ensuring that the goals of the plan are considered and modified as needed, and to offer support to the team, the patient, and the family for the success of the care delivery. The care management phase is to evaluate the goals, modify the plan as needed, and to support the care team, patient, and family as needed to meet the goals of the AIMS model. Under which step are there guidelines for the system navigator? - Step 3 Step 3 is where the Systems Navigator has specific guidelines for care planning. Under which step are there care conference guidelines? - Step 2 Step 2 is where the client goals and needs are assessed and the care team members are identified. Under which step is the Patient Post Card? - Step 1 Step 1 is when the identification and referral information is completed and tracked.