CPHQ Care Transition Processes 2 — Questions and Answers
Question 1: The Care Transitions Intervention (CTI) developed by Eric Coleman focuses primarily on which four pillars?
- Medication self-management, patient-centered record, follow-up, red flag awareness (Correct answer)
- Discharge planning, transportation, home safety, caregiver training
- Provider communication, insurance verification, medication reconciliation, diet education
- Nursing handoff, physician rounds, family meeting, social work consult
Correct answer: Medication self-management, patient-centered record, follow-up, red flag awareness
Coleman's CTI model centers on medication self-management, a patient-centered health record, timely follow-up, and knowledge of red flags indicating deterioration.
Question 2: A patient is discharged from the hospital but readmitted within 30 days for the same condition. Under CMS value-based purchasing, this most directly affects which hospital metric?
- Hospital-Acquired Condition (HAC) score
- Hospital Readmissions Reduction Program (HRRP) penalty (Correct answer)
- Patient Safety Indicator (PSI) rate
- Length of stay benchmark
Correct answer: Hospital Readmissions Reduction Program (HRRP) penalty
The HRRP penalizes hospitals with excess readmissions within 30 days for specific conditions by reducing Medicare payments.
Question 3: Which handoff tool uses a structured format with Situation, Background, Assessment, and Recommendation components during care transitions?
- IDEAL
- SBAR (Correct answer)
- IPASS
- AIDET
Correct answer: SBAR
SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool widely used during clinical handoffs to ensure critical information is conveyed.
Question 4: A quality team wants to reduce post-discharge medication errors. Which intervention is MOST effective as a first step?
- Providing written discharge instructions in large font
- Conducting medication reconciliation at all transition points (Correct answer)
- Limiting the number of medications prescribed at discharge
- Requiring pharmacist review only for high-risk medications
Correct answer: Conducting medication reconciliation at all transition points
Medication reconciliation at every transition point is the foundational intervention for catching discrepancies that cause post-discharge medication errors.
Question 5: The Transitional Care Model (TCM) developed by Mary Naylor is best characterized by which approach?
- Emergency department case managers coordinating readmissions
- Advanced practice nurses providing in-home follow-up after hospital discharge (Correct answer)
- Telehealth monitoring of vital signs for 90 days post-discharge
- Social workers managing financial barriers to outpatient care
Correct answer: Advanced practice nurses providing in-home follow-up after hospital discharge
Naylor's TCM uses advanced practice nurses who follow high-risk patients from hospital to home, providing comprehensive post-discharge support.
Question 6: When assessing the quality of care transitions, which metric is considered the most direct indicator of transition failure?
- Average length of inpatient stay
- Unplanned 30-day hospital readmission rate (Correct answer)
- Patient satisfaction scores at discharge
- Emergency department utilization rate at 90 days
Correct answer: Unplanned 30-day hospital readmission rate
Unplanned 30-day readmissions are widely accepted as the most direct measurable indicator that a care transition was inadequate or failed.
Question 7: A care transitions coordinator notices that patients transferred from ICU to medical-surgical units frequently experience lapses in antibiotic therapy. Which process improvement should be prioritized?
- Increasing nurse-to-patient ratios on med-surg floors
- Implementing a structured intra-hospital handoff checklist that includes active medication orders (Correct answer)
- Requiring physician re-ordering of all medications at unit transfer
- Training unit nurses in ICU-level medication administration
Correct answer: Implementing a structured intra-hospital handoff checklist that includes active medication orders
A structured handoff checklist that explicitly includes active medication orders ensures continuity of therapy and reduces dangerous gaps during intra-hospital transfers.
CPHQ Care Transition Processes 2
The Care Transitions Intervention (CTI) developed by Eric Coleman focuses primarily on which four pillars?