1
NURS 242 Exam 3| LATEST|COMPLETE
FREQUENTLY MOST TESTED QUESTIONS
WITH VERIFIED ANSWERS/ALREADY
GREADED A+ |GET IT 100% ACCURATE!!
Care Coordination - (ANSWER)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 - (ANSWER)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 -
(ANSWER)-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
,2
-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 - (ANSWER)-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 - (ANSWER)-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
,3
-Patients most likely to benefit identified
-Patient-centered and family-focused
Targeted set of purposeful activities - (ANSWER)-Individual's needs, preferences,
and risks assessed
-Evidence-based standards of care and referrals followed
-Shared decision making
-Activities matched to goals
-Self-care skills and independence promoted
-Duplicated services and unnecessary cost avoided
-Health promotion activities included
Proactive follow-up - (ANSWER)-Systematic surveillance, evaluation, and
monitoring of patient and process including follow-up assessments, tests,
treatments, or services
Theoretical Links of Care Coordination - (ANSWER)1. Specific Patient Care
Situation- care coordination begins with an assessment of the individual patient
situation that includes needs and resources within the health care system,
community, and home based on current standards of care
2. Coordination Mechanisms- goals, team dynamics, exchange of information
3. Outcomes of Care- ongoing process, quality outcomes should be evidence
based, patient-centered, substantive, and interprofessional. Continually assess to
improve outcomes and maintain cost-effective care
, 4
Target of Care Coordination Efforts - (ANSWER)-Care coordination is important
for everyone
-The general population needs to be stratified based on risk and need
-To satisfy those in greatest need, care coordination may need to be reserved to
those particularly vulnerable
*Social Models* - (ANSWER)-Supports activities of daily living rather than skilled
care. May vary based on need. Organized to offer information, referral, screening
and assessment, planning, authorization, and monitoring. Having a single entity
coordinate all relevant social services can reduce the likelihood of redundancy
and duplication of efforts. Important part of promoting health and independence
in the community.
*Medically Oriented Models* - (ANSWER)Coordinate medical services and were
traditionally designed to be diagnosis specific. New models emerged since
patients now need multiple treatments or have multiple conditions. Financing
further challenges the ability to coordinate care across settings and over time.
Providers and patients have come to realize the limitations of addressing only the
medical needs of patients and their families.
Integrated Models - (ANSWER)Models committed to the integration of health
care, social support, and community clinical and non-clinical services that are still
evolving. They offer significant promise for supporting holistic, patient-centered,
family-focused care, but building bridges between services and settings is fraught
with barriers. Fully integrated models need to be able to coordinate a full range of
services across settings and over time.
NURS 242 Exam 3| LATEST|COMPLETE
FREQUENTLY MOST TESTED QUESTIONS
WITH VERIFIED ANSWERS/ALREADY
GREADED A+ |GET IT 100% ACCURATE!!
Care Coordination - (ANSWER)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 - (ANSWER)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 -
(ANSWER)-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
,2
-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 - (ANSWER)-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 - (ANSWER)-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
,3
-Patients most likely to benefit identified
-Patient-centered and family-focused
Targeted set of purposeful activities - (ANSWER)-Individual's needs, preferences,
and risks assessed
-Evidence-based standards of care and referrals followed
-Shared decision making
-Activities matched to goals
-Self-care skills and independence promoted
-Duplicated services and unnecessary cost avoided
-Health promotion activities included
Proactive follow-up - (ANSWER)-Systematic surveillance, evaluation, and
monitoring of patient and process including follow-up assessments, tests,
treatments, or services
Theoretical Links of Care Coordination - (ANSWER)1. Specific Patient Care
Situation- care coordination begins with an assessment of the individual patient
situation that includes needs and resources within the health care system,
community, and home based on current standards of care
2. Coordination Mechanisms- goals, team dynamics, exchange of information
3. Outcomes of Care- ongoing process, quality outcomes should be evidence
based, patient-centered, substantive, and interprofessional. Continually assess to
improve outcomes and maintain cost-effective care
, 4
Target of Care Coordination Efforts - (ANSWER)-Care coordination is important
for everyone
-The general population needs to be stratified based on risk and need
-To satisfy those in greatest need, care coordination may need to be reserved to
those particularly vulnerable
*Social Models* - (ANSWER)-Supports activities of daily living rather than skilled
care. May vary based on need. Organized to offer information, referral, screening
and assessment, planning, authorization, and monitoring. Having a single entity
coordinate all relevant social services can reduce the likelihood of redundancy
and duplication of efforts. Important part of promoting health and independence
in the community.
*Medically Oriented Models* - (ANSWER)Coordinate medical services and were
traditionally designed to be diagnosis specific. New models emerged since
patients now need multiple treatments or have multiple conditions. Financing
further challenges the ability to coordinate care across settings and over time.
Providers and patients have come to realize the limitations of addressing only the
medical needs of patients and their families.
Integrated Models - (ANSWER)Models committed to the integration of health
care, social support, and community clinical and non-clinical services that are still
evolving. They offer significant promise for supporting holistic, patient-centered,
family-focused care, but building bridges between services and settings is fraught
with barriers. Fully integrated models need to be able to coordinate a full range of
services across settings and over time.
