Interdisciplinary Team Collaboration and Care Coordination Flashcards
7 cards from real ACHPN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Interdisciplinary Team Collaboration and Care Coordination flashcards as text
A palliative care team is caring for a patient from a cultural background that discourages direct disclosure of terminal prognosis. How should the IDT approach this situation?
Answer: Explore with the family and patient what level of information they wish to receive and honor their preferences within legal and ethical boundaries
Culturally sensitive care requires exploring patient and family information preferences and tailoring communication to honor those preferences within ethical constraints.
Which of the following documentation practices BEST supports continuity of care across the palliative care IDT?
Answer: A shared, integrated care plan updated after each IDT meeting and accessible to all team members
A shared, integrated care plan accessible to all disciplines ensures consistent care delivery and prevents miscommunication across the team.
A family member requests that the hospice team not tell the patient they are dying. The patient has capacity. What is the most appropriate IDT response?
Answer: Discuss the family's concerns while affirming the patient's right to information, and explore a communication approach that addresses both
The IDT must balance family concerns with the autonomous patient's right to information, using collaborative communication to find a respectful approach.
Which element is MOST essential when coordinating care transitions from inpatient palliative care to home hospice?
Answer: A structured handoff that includes goals of care, symptom management plan, family support needs, and 24-hour contact information
Effective transitions require comprehensive handoff communication covering clinical, psychosocial, and logistical needs with clear family instructions and emergency contacts.
In palliative care, SBAR (Situation, Background, Assessment, Recommendation) is most useful for:
Answer: Standardizing clinical communication during urgent handoffs or escalations between IDT members
SBAR provides a structured format for concise, complete communication during clinical escalations and handoffs, reducing errors in high-stakes situations.
A hospice nurse identifies that a patient's pain is no longer controlled on the current regimen. Which IDT coordination step should occur FIRST?
Answer: Document the change, reassess comprehensively, and notify the prescribing clinician with SBAR communication
Immediate documentation, reassessment, and structured notification to the prescriber ensures prompt, safe clinical response to uncontrolled pain.
Which characteristic BEST distinguishes a high-functioning palliative care IDT from a multidisciplinary team?
Answer: Team members engage in shared decision-making, mutual learning, and blurred role boundaries in service of patient goals
In a high-functioning IDT, team members engage collaboratively across discipline boundaries, sharing knowledge and decision-making to achieve patient-centered goals.