Question 1

An older adult recovering from a fractured hip is surprised to discover an RN will be providing care coordination during the individual's recovery. Which is the best explanation the nurse can give when the individual asks the reason for this?

A)"By coordinating your care I can ensure you get the best and right treatment."
B)"Having a nurse provide care coordination is mandated by your insurance company."
C)"Care coordination will help avoid complications during your recovery."
D)"Government regulations now require RNs to coordinate care."

"By coordinating your care I can ensure you get the best and right treatment."

Accepted Answer

The use of care coordination has been shown to provide better care quality, more efficient use of resources, and lower healthcare costs. In essence, it helps ensure the individual gets the best treatment possible by simplifying care and reducing confusion. Complications may be avoided as a result of proper care coordination, but this would be a secondary benefit rather than the primary reason for practicing care coordination. Currently, it is not necessarily mandated by insurance companies, nor is it required by government regulations.

Question 2

An individual with Parkinson's disease has been receiving care at home from family members and has recently begun showing signs of increasing degeneration. The family members are concerned they will no longer be able to provide adequate care. Which method will best assist the family in this situation?

A)Care management
B)Care coordination
C)Case management
D)Nurse navigation

Care management

Accepted Answer

Case management refers to team-based approaches to care. Its purpose is to assist individuals and their caregivers in managing health-related conditions across providers and services. It differs from care coordination in that case management is a more episodic approach. Care coordination is a multidimensional concept that includes effective communication among all parties involved, safe care transitions, a view of care that considers the past while looking at the present and anticipating future needs, and ensuring links between the communities and healthcare systems. Case management involves helping the individual navigate from one level of care to another. Nurse navigation is a singular intervention that offers individualized assistance for overcoming healthcare system barriers.

Question 3

An ambulatory care nurse has been recognized for providing high quality of care when assisting various individuals. Which of the following traits together would indicate this nurse is ready to transition to a care coordinator position? Select all that apply.

A)Utilizes evidence-based practice on a daily basis
B)Effectively communicates using a variety of formats
C)Takes advantage of educational opportunities
D)Follows recommendations of the organization's leaders
E)Recommends appropriate resources for each individual

Utilizes evidence-based practice on a daily basis
Effectively communicates using a variety of formats
Takes advantage of educational opportunities
Recommends appropriate resources for each individual

Accepted Answer

The professional performance standards for CCTM include maintaining ongoing knowledge and competence of current EBP; integrating relevant research to maintain and optimize best practices; communicating effectively through a variety of formats to build relationships and deliver care; and utilizing appropriate resources that are safe, effective, and fiscally responsible. While any RN working at a high skill level could be expected to demonstrate one or more of these traits as needed in a particular situation, a nurse in a care coordination position would be expected to exemplify these standards together at all times. The nurse preparing for a care coordinator position should also acquire and utilize leadership rather than waiting on the recommendations of other members of the organization.

Question 4

The ambulatory care nurse is preparing a presentation for a health fair that will explain care coordination to the community. Which of the following examples can the nurse include when discussing the care coordinator role with the individuals attending the health fair? Select all that apply.

A)The care coordination RN helps the individual obtain a discount for an expensive medication.
B)The care coordination RN arranges for the individual with transportation issues to schedule lab and diagnostic tests for the same day.
C) The care coordination RN ensures that the referral specialist has all the necessary information for the individual.
D)The care coordination RN provides triage only, for the individual to be seen by the provider.
E)The care coordination RN advises the individual as to which type of insurance would be best to purchase.

Accepted Answer

It is important for the nurse to point out that the care will be coordinated by one person to ensure each community member will get the best care possible. Providing various examples of the standards of practice for the care coordinator can help demonstrate the many ways care coordinators can help individuals. The care coordination process is multidimensional, requiring the nurse to be involved in many areas of the individual's care, not just triage. It is outside the scope of practice for the care coordination RN to give insurance advice to the individual.

Question 5

An RN is assisting with the transition from the hospital to home for an older adult and has identified the following challenges. Although all of these issues will be addressed, which one would present the greatest obstacle to effective care transition?

A)Lack of technology skills/resources at home
B)Decreased ADL skills
C) Tripping hazards in the home
D)Lack of cooperation from family members

Accepted Answer

Many older adults do not have the equipment and/or skills to operate today's technologic devices, so this could limit the options the nurse has to communicate and share information with the individuals, especially if the older adult is living at home and no younger family members are available to assist with this activity. The other choices should alert the nurse to the possibility that discharging the individual to the home may not be the best option, but rather the individual should spend time in a care facility until living independently is possible.

Question 6

The ambulatory care nurse has been working toward improving the outcomes of the individuals who come to the clinic. Which action should be the priority for the nurse and the rest of the clinic staff?&#10;A)Include the individuals in decision-making.&#10;B)Ensure each family has received appropriate education.&#10;C)Assign one staff member to call and check on individuals.&#10;D)Make decisions for each individual based on the situation.

Accepted Answer

Patient-centeredness is foundational to quality healthcare. This includes providing care that is respectful to patients' values, preferences, and expressed needs; coordinating and integrating care; providing information, communication, and education to the individuals; ensuring physical comfort to all individuals; providing emotional support to all; and involving family and friends in the process. The other choices are possible actions that can be used when providing care; however, including the individual is the priority.

Question 7

The individual with diabetes has been reluctant to make lifestyle changes necessary for improving health status. Which actions by the ambulatory care nurse can help encourage this individual to become more involved in the treatment protocol? Select all that apply.

A)Look for reasons the individual is not changing.
B)Give the individual a pamphlet detailing potential complications if changes are not made.
C)Point out why the suggested changes will be worthwhile.
D)Ensure the individual knows the rewards for making changes.
E)Mention that the individual can help improve the outcome statistics of the clinic.

Accepted Answer

If an individual is not quite ready to engage in behavior change, the 5Rs can be an effective strategy to correct this. The 5Rs include discussing the relevance of change; outlining the risks of continuing the unhealthy behavior; listing the rewards of adapting healthy behavior; identifying roadblocks to changing the behavior; and repeating the personalized 5Rs message at each visit. The focus is not on improving the statistics of the clinic but improving the health of the individual.

Question 8

The ambulatory care nurse is preparing a care plan for a young child recently diagnosed with autism. Which considerations for this family should the nurse include when developing this care plan? Select all that apply.

A)Ensure parents have a basic knowledge of this condition.
B)Connect the family with available resources in the local community.
C)Develop a plan that will reduce financial hardship.
D)Inform the individual of the recommended care plan of the primary care provider.
E)Ensure a comprehensive assessment is completed.

Accepted Answer

When interacting with individuals, there are certain nursing standards and competencies that the ambulatory care nurse must complete. An assessment must be completed so that a proper care plan can be created to best meet the individual's needs. Next, the diagnosis must be identified, then the outcome identification is made. This should involve the patient, family, and healthcare team in formulating measurable expected outcomes. The planning step should include the patient, family, or caregivers as appropriate and the healthcare team in making shared decisions about prioritizing plans and strategies. It should also consider the economic impact of the plan on the patient and family resources. While coordinating care, the nurse should educate the patient and caregivers about optimal disease management. It would be inappropriate to merely inform the individual of what the primary care provider wants the individual to do. The individual is to have a voice in the treatment plan.

Question 9

The ambulatory care nurse has invited several individuals to become more involved in helping the clinic improve the healthcare provided. Which is the best response when some colleagues question this action?

A)Explain that similar actions have proven to be beneficial.
B)Point out that a competing clinic is already doing this.
C)Tell that doing so will increase customer satisfaction.
D)Mention the opportunity to decrease healthcare costs.

Accepted Answer

Organizations that incorporate the individual's values and perspectives into the design and governance of healthcare organizations have discovered that integrating individual preferences is foundational to healthcare delivery. It has been proven that allowing individuals to be engaged early in the design and planning discussions and empowered to develop agendas, set priorities, and have shared decision-making authority provides better guidance to the organization and key initiatives. The other choices may be correct some of the time but are not the primary reason for implementing such a program.

Deck 6: Care Coordination, Engaging Individuals and Families in Health