Care Transition Management Flashcards

Which social determinant of health most frequently disrupts care transitions for low-income patients returning home from the hospital?

Answer: Lack of transportation to follow-up appointments

Transportation barriers are one of the most common social determinants that prevent low-income patients from attending post-discharge follow-up appointments and accessing medications.

A case manager is reviewing a patient's transition to home after hip replacement surgery. Which finding would MOST concern the case manager regarding fall risk?

Answer: The patient lives alone in a two-story home with the only bathroom upstairs

A post-surgical patient living alone with required stair-climbing to access the bathroom faces a high fall risk that must be addressed before or immediately after discharge.

When a case manager identifies that a patient's post-discharge medications are not covered by their insurance plan, the FIRST step is to:

Answer: Contact the prescribing physician to request a formulary-covered therapeutic alternative

Working with the physician to substitute a covered alternative is the fastest, safest solution—ensuring the patient receives needed therapy without delay or financial hardship.

The RED (Re-Engineered Discharge) program is an evidence-based transition intervention that MOST emphasizes:

Answer: A structured nurse-led discharge process with 11 mutually reinforcing components

Project RED (Boston University/BMC) uses a nurse 'discharge advocate' who applies 11 standardized components including written care plans, medication review, and a post-discharge phone call to reduce readmissions.

A case manager is assessing a patient's caregiver for ability to manage care at home after discharge. Which caregiver factor would MOST increase the patient's risk of readmission?

Answer: The caregiver expresses feeling overwhelmed and has no backup support

Caregiver burnout and lack of backup support directly compromise the quality of home care, increasing the likelihood of unmanaged complications and emergency readmission.

Which approach BEST supports continuity of care when a patient transitions from a hospitalist's care back to a primary care physician (PCP)?

Answer: Sending a complete discharge summary to the PCP before the follow-up appointment and confirming the appointment was scheduled

Proactive transmission of the discharge summary combined with a confirmed follow-up appointment closes the most common communication gaps between hospital and outpatient care.

A case manager is preparing a transition plan for a patient with advanced heart failure who has expressed a wish to avoid future hospitalizations. The MOST appropriate next step is to:

Answer: Initiate a goals-of-care conversation and consider a palliative care referral aligned with the patient's wishes

When a patient with serious illness expresses a preference to avoid hospitalization, goals-of-care discussion and palliative care referral align the care plan with the patient's values and can improve quality of life.