Ambulatory Care Care Coordination and Transitions Questions and Answers

Question 1

A 72-year-old patient with congestive heart failure, diabetes, and chronic kidney disease is being discharged from the hospital to home.
Which of the following is the MOST critical initial action for the ambulatory care nurse coordinator to take to ensure a safe transition?

Accepted Answer

Performing a comprehensive medication reconciliation within 48 hours of discharge.

Answer

Scheduling a follow-up appointment with the patient's primary care provider within 7-14 days.

Answer

Arranging for home health aide services to assist with activities of daily living.

Answer

Providing the patient with a brochure on low-sodium dietary choices.

Question 2

The Care Transitions Intervention (CTI) model is a patient-centered approach designed to improve the quality of care transitions. Which of the following is a core component, or 'pillar,' of this model?

Accepted Answer

Focus on patient self-management of medications and a personal health record.

Answer

Direct provision of clinical care by a Transition Coach.

Answer

Long-term case management for at least six months post-discharge.

Answer

Mandatory daily telehealth monitoring for all enrolled patients.

Question 3

An ambulatory care clinic is implementing a new workflow to improve care coordination for patients transitioning from an inpatient psychiatric facility back to the community. Which action is the highest priority for the care coordinator?

Accepted Answer

Facilitating a 'warm handoff' call between the inpatient and outpatient providers before discharge.

Answer

Ensuring the patient has transportation to their first outpatient therapy appointment.

Answer

Verifying that the patient's insurance will cover their prescribed psychotropic medications.

Answer

Providing the patient's family with a list of local support groups.

Question 4

Which of the following is the primary goal of Transitional Care Management (TCM) services as defined by the Centers for Medicare & Medicaid Services (CMS)?

Accepted Answer

To reduce preventable hospital readmissions within 30 days of discharge.

Answer

To provide long-term, home-based primary care for chronically ill patients.

Answer

To manage the billing and coding for all post-hospitalization services.

Answer

To solely provide medication delivery services to patients' homes after discharge.

Question 5

A patient is being discharged from the hospital after a myocardial infarction. The ambulatory care coordinator uses the 'teach-back' method when reviewing the discharge instructions. This technique primarily addresses which potential barrier to a successful care transition?

Accepted Answer

Low health literacy.

Answer

Lack of social support at home.

Answer

Financial inability to afford medications.

Answer

Transportation difficulties to follow-up appointments.

Question 6

During a post-discharge follow-up call, an ambulatory care nurse learns that a patient has not filled their new prescription for an anticoagulant because they are worried about the cost. Which of the following is the most appropriate immediate action by the nurse?

Accepted Answer

Explore solutions such as pharmacy assistance programs or contacting the provider to discuss therapeutic alternatives.

Answer

Advise the patient to take half the dose to make the prescription last longer.

Answer

Document the non-adherence in the chart and wait for the next office visit.

Answer

Educate the patient on the risks of not taking the medication as prescribed.