D055 Evidenced-Based Practice for
Care Coordination
A care coach is another name for this role - Care coordinator
A care coach is another name for care coordinator.
A care coordinator is planning for a patient's upcoming surgery and postoperative
needs. During a planning session, the surgeon states, "The patient is from Mexico so
home care visits will be needed to ensure compliance with post-op care." The primary
care physician (PCP) immediately responds, "What makes you think my patient will not
comply? What a racist thing to say!"
Which statement by the care coordinator attempts to foster collaboration among the
healthcare team? - "We have a misunderstanding. Please explain again so everyone
understands."
This statement shows reflection and allows for restatement and correction if necessary.
A care coordinator is working with a client who is a recent immigrant. The coordinator is
discussing a culturally competent care plan and wants to hold a conversation about the
client's perceptions of the treatment options.
Which question is appropriate to ask this client? - "What do you call your health
problem?"
This will help generate a conversation about the client's perceptions and help develop a
culturally sensitive care plan. This gives the client an opportunity to use his own
terminology to talk about his health history.
A case manager is arranging discharge plans for an older adult who requires continuous
tube feedings. The patient will be discharged home within 24 hours to the care of a
family member.
What is the appropriate referral process in preparing this patient for discharge? -
Consult a dual medical supply company to furnish the needed supplies and equipment
This company will supply the needed supplies and equipment for someone being
discharged to home as well as the tube-related supply support.
A case manager is concerned that discharge instructions provided to patients have
been incomplete and patient outcomes are being impacted. The case manager
performs a literature review on evidence-based practice (EBP) related to the issue.
Which action should the case manager take to improve these outcomes now that the
literature review is completed? - Conduct a focus group with nurses
The case manager requires deeper understanding of the problem related to care
transitions. Focus groups are a way to get a selected group of people together to
discuss a topic. Clear understanding of the problem will support evidence-based
practices designed to address the problem.
,A culturally diverse interprofessional healthcare team is working with a healthcare
coordinator to prepare a care plan for a patient with mental and physical illnesses. What
action will promote successful interprofessional collaboration among the team
members? - Aligning values to meet the patient's needs.
A healthcare coordinator works with a variety of healthcare professionals as a liaison, or
coordinator, of patient care. This requires the healthcare professionals to collaborate
and work together as a team.
A discharge planner is reviewing a patient's needs after leaving the hospital. The patient
has been discharged after abdominal surgery, is ambulatory, and remains on narcotics
for pain control.
Which situation should the planner address? - The patient will be unable to drive after
discharge.
This situation is directly related to the discharge plan itself and must be addressed by
the planner.
A diverse healthcare employee population promotes what for diverse clients? - Better
outcomes
A diverse healthcare employee population promotes better outcomes for diverse clients.
A health services coordinator is engaging a patient in developing a plan of care for
smoking cessation.
Which technique would involve positive engagement? - Using active listening
Using active listening helps to build a stronger, more open and honest relationship with
the patient and helps the patient work toward smoking cessation goals with positive
engagement. Active listening allows open discussion between the coordinator and
patient as to which strategies and techniques would best work for the patient to achieve
this goal.
A healthcare coordinator arranges an appointment at a specialist physician's office that
the patient has been referred to by a primary care physician. The healthcare coordinator
sends an electronic referral to the specialist's office. How can the healthcare coordinator
prevent any delay in the patient's consultation or treatment? - Track the referral
electronically to verify that it was sent and received.
It is the healthcare coordinator's responsibility to send clinical information to the
specialty physician's office and follow up to ensure it was received. This is done easily
using software that tracks the process.
A healthcare coordinator at a clinic observes that patient who is older is missing
appointments for follow-up care after a surgery. The patient tells the healthcare
coordinator that is difficult to drive into the city to get to the appointments. What can the
healthcare coordinator do to encourage patient adherence to the treatment plan? -
Discuss other transportation options with the patient.
By helping the patient to seek assistance from resources, such as family, friends, or
community organizations, the healthcare coordinator can present transportation options
to the patient that remove the barrier of not feeling comfortable driving in the city. By
, removing this barrier, the patient will be more likely to adhere to the treatment plan by
coming to scheduled appointments.
A healthcare coordinator at a community clinic is arranging for care for a patient in a
long-term nursing facility. The patient is low-income and does not have insurance, but
will require skilled nursing care. How can the healthcare coordinator meet the patient's
care needs using critical thinking skills? - Arrange for a social worker to assist the
patient in applying for financial assistance.
The healthcare coordinator should collaborate with a social worker to assist the patient
in applying for financial benefits for necessary rehabilitation care. This collaboration will
assist in meeting the patient's financial needs.
A healthcare coordinator at a community health clinic is discussing care with a patient
who has type 2 diabetes mellitus. The patient wants to get the disease under control
with a care plan and knows that some lifestyle changes are needed, but has struggled
to make healthy decisions. Which would be appropriate short- and long-term goals for
the healthcare coordinator to suggest to the patient? - "Keep a diet diary, and gradually
work to modify your diet to be healthier."
A healthcare coordinator should use critical thinking skills to assist a patient in setting
realistic long- and short-term healthcare goals. By keeping a diet diary, the patient will
be able to critically evaluate what changes are needed, then slowly implement those
changes in a practical way.
A healthcare coordinator at a community public health clinic is discussing a care plan
with a patient who lives in a rural area. The care plan includes taking a medication
available from a specialty pharmacy. Which would be an appropriate action to increase
the likelihood that the patient will follow through with taking prescribed medication? -
Ask if the patient knows of a pharmacy that is able to fill the prescription for the
medication.
Appropriate questions to gather information allow the healthcare coordinator to improve
the patient's outcome. To increase the likelihood that the patient will follow through with
taking the medication, the healthcare coordinator can help the patient find a pharmacy
where the prescription can be filled or suggest an alternate resource, such as a mail-
away pharmacy.
A healthcare coordinator at a correction facility healthcare clinic is seeking to improve
inmate health outcomes. How can the healthcare coordinator apply the Calian Group
model of care? - Contract physicians to provide inmate care onsite
The Calian Group developed a care model for correctional facilities that provides
greater access to services through contracting local physicians. The model decreases
the need to transport prisoners to the hospital for care, which saves time, money, and
resources.
A healthcare coordinator at a hospital is coordinating care for a patient who has
Medicare and pays a monthly premium for Part B coverage. The patient is receiving
Care Coordination
A care coach is another name for this role - Care coordinator
A care coach is another name for care coordinator.
A care coordinator is planning for a patient's upcoming surgery and postoperative
needs. During a planning session, the surgeon states, "The patient is from Mexico so
home care visits will be needed to ensure compliance with post-op care." The primary
care physician (PCP) immediately responds, "What makes you think my patient will not
comply? What a racist thing to say!"
Which statement by the care coordinator attempts to foster collaboration among the
healthcare team? - "We have a misunderstanding. Please explain again so everyone
understands."
This statement shows reflection and allows for restatement and correction if necessary.
A care coordinator is working with a client who is a recent immigrant. The coordinator is
discussing a culturally competent care plan and wants to hold a conversation about the
client's perceptions of the treatment options.
Which question is appropriate to ask this client? - "What do you call your health
problem?"
This will help generate a conversation about the client's perceptions and help develop a
culturally sensitive care plan. This gives the client an opportunity to use his own
terminology to talk about his health history.
A case manager is arranging discharge plans for an older adult who requires continuous
tube feedings. The patient will be discharged home within 24 hours to the care of a
family member.
What is the appropriate referral process in preparing this patient for discharge? -
Consult a dual medical supply company to furnish the needed supplies and equipment
This company will supply the needed supplies and equipment for someone being
discharged to home as well as the tube-related supply support.
A case manager is concerned that discharge instructions provided to patients have
been incomplete and patient outcomes are being impacted. The case manager
performs a literature review on evidence-based practice (EBP) related to the issue.
Which action should the case manager take to improve these outcomes now that the
literature review is completed? - Conduct a focus group with nurses
The case manager requires deeper understanding of the problem related to care
transitions. Focus groups are a way to get a selected group of people together to
discuss a topic. Clear understanding of the problem will support evidence-based
practices designed to address the problem.
,A culturally diverse interprofessional healthcare team is working with a healthcare
coordinator to prepare a care plan for a patient with mental and physical illnesses. What
action will promote successful interprofessional collaboration among the team
members? - Aligning values to meet the patient's needs.
A healthcare coordinator works with a variety of healthcare professionals as a liaison, or
coordinator, of patient care. This requires the healthcare professionals to collaborate
and work together as a team.
A discharge planner is reviewing a patient's needs after leaving the hospital. The patient
has been discharged after abdominal surgery, is ambulatory, and remains on narcotics
for pain control.
Which situation should the planner address? - The patient will be unable to drive after
discharge.
This situation is directly related to the discharge plan itself and must be addressed by
the planner.
A diverse healthcare employee population promotes what for diverse clients? - Better
outcomes
A diverse healthcare employee population promotes better outcomes for diverse clients.
A health services coordinator is engaging a patient in developing a plan of care for
smoking cessation.
Which technique would involve positive engagement? - Using active listening
Using active listening helps to build a stronger, more open and honest relationship with
the patient and helps the patient work toward smoking cessation goals with positive
engagement. Active listening allows open discussion between the coordinator and
patient as to which strategies and techniques would best work for the patient to achieve
this goal.
A healthcare coordinator arranges an appointment at a specialist physician's office that
the patient has been referred to by a primary care physician. The healthcare coordinator
sends an electronic referral to the specialist's office. How can the healthcare coordinator
prevent any delay in the patient's consultation or treatment? - Track the referral
electronically to verify that it was sent and received.
It is the healthcare coordinator's responsibility to send clinical information to the
specialty physician's office and follow up to ensure it was received. This is done easily
using software that tracks the process.
A healthcare coordinator at a clinic observes that patient who is older is missing
appointments for follow-up care after a surgery. The patient tells the healthcare
coordinator that is difficult to drive into the city to get to the appointments. What can the
healthcare coordinator do to encourage patient adherence to the treatment plan? -
Discuss other transportation options with the patient.
By helping the patient to seek assistance from resources, such as family, friends, or
community organizations, the healthcare coordinator can present transportation options
to the patient that remove the barrier of not feeling comfortable driving in the city. By
, removing this barrier, the patient will be more likely to adhere to the treatment plan by
coming to scheduled appointments.
A healthcare coordinator at a community clinic is arranging for care for a patient in a
long-term nursing facility. The patient is low-income and does not have insurance, but
will require skilled nursing care. How can the healthcare coordinator meet the patient's
care needs using critical thinking skills? - Arrange for a social worker to assist the
patient in applying for financial assistance.
The healthcare coordinator should collaborate with a social worker to assist the patient
in applying for financial benefits for necessary rehabilitation care. This collaboration will
assist in meeting the patient's financial needs.
A healthcare coordinator at a community health clinic is discussing care with a patient
who has type 2 diabetes mellitus. The patient wants to get the disease under control
with a care plan and knows that some lifestyle changes are needed, but has struggled
to make healthy decisions. Which would be appropriate short- and long-term goals for
the healthcare coordinator to suggest to the patient? - "Keep a diet diary, and gradually
work to modify your diet to be healthier."
A healthcare coordinator should use critical thinking skills to assist a patient in setting
realistic long- and short-term healthcare goals. By keeping a diet diary, the patient will
be able to critically evaluate what changes are needed, then slowly implement those
changes in a practical way.
A healthcare coordinator at a community public health clinic is discussing a care plan
with a patient who lives in a rural area. The care plan includes taking a medication
available from a specialty pharmacy. Which would be an appropriate action to increase
the likelihood that the patient will follow through with taking prescribed medication? -
Ask if the patient knows of a pharmacy that is able to fill the prescription for the
medication.
Appropriate questions to gather information allow the healthcare coordinator to improve
the patient's outcome. To increase the likelihood that the patient will follow through with
taking the medication, the healthcare coordinator can help the patient find a pharmacy
where the prescription can be filled or suggest an alternate resource, such as a mail-
away pharmacy.
A healthcare coordinator at a correction facility healthcare clinic is seeking to improve
inmate health outcomes. How can the healthcare coordinator apply the Calian Group
model of care? - Contract physicians to provide inmate care onsite
The Calian Group developed a care model for correctional facilities that provides
greater access to services through contracting local physicians. The model decreases
the need to transport prisoners to the hospital for care, which saves time, money, and
resources.
A healthcare coordinator at a hospital is coordinating care for a patient who has
Medicare and pays a monthly premium for Part B coverage. The patient is receiving
