A patient arrives at your organization and needs specific care. Recently, your organization signed an agreement with a university health system to allow
... [Show More] for telehealth assessment and identification of potential treatment options.
As the coordinator for this patient, what would be the next step to determine if this is a good solution?
Contact the leadership team and the telehealth informatics specialist to identify whether everything is in place for this patient to receive care through this association.
Telehealth initiatives have associated a lot of organizations with university and other larger health systems to facilitate a collaborative practice for care delivery.
A patient is ready to go home, and the family has expressed concern about the patient being on her own during the day. The patient is unable to complete full activities of daily living due to a recent injury.
Is there something that the coordination team can recommend for provision of lunch or dinner?
Recommend that the family contact the local Meals on Wheels program, so they can ensure the patient has access to food and drink during the day.
The patient has some activities for daily living but is not able to complete all activities. Since the concern is around food during the day, the coordinator identified a service that provides free or reduced delivery of hot meals one time a day. Use of this service also provides reassurance for the family that someone has checked on the patient that day.
The care team has determined that to reverse behaviors of smoking, a patient and family should seek ongoing support.
What recommendations would the care coordinator make?
The care coordinator recommends current community outreach programs available and assists the patient and family in deciding which option will meet their needs.
The care coordinator should have a list of partners in the community who can assist patients and families, encouraging compliance and promoting health wellness.
Provide an example of the clinic-clinician patient relationship.
Examples of the clinic-clinician patient relationship include trust between the clinician and patient, shared decision-making, and mechanisms for mutual support of patient self-management.
Provide an example of the clinic-clinician-community resource relationship.
Examples of the clinic-clinician-community resource relationship include the level of interrelationship along Himmelman's continuum for collaborative processes, formal mechanisms for referrals, and effective mechanisms for feedback from community resource to clinic.
Provide an example of the patient-community resource relationship.
Examples of the patient-community resource relationship include patients' perception and trust of the community resource, formal mechanisms for referrals, and effective communication between patient and community resource.
Using health technology to gather patient-specific data in their electronic health record, how could the care coordination team focus care on an individual patient?
Using the data collected provides a collection of problems and diagnosis-related groups (DRGs) that can help the care team determine discharge needs. Review of demographic data can provide information after validation that the information is correct during the assessment phase of contact with the patient and family.
The electronic health record is a tool used by the coordination team and others to gather information on what is going on with the patient, by providing information on both the current situation and the medical history. It can also include advance directive information for the future.
Where should the documentation of the care plan be recorded?
In the care planning module of the electronic health record
The electronic health record is where all the care team members have access to the record of the patient, and it is the official health record for that patient.
A pregnant client is living in the wilds of Alaska. She is not considered to be high risk and there is no reason for her to stay close to town since a frontier midwife is available to travel to her home every month.
What would the care coordinator recommend for the client?
Satellite telecommunications device
A satellite phone is recommended to ensure that if any questions arise when the midwife is not available, the client can call for help.
Which statement describes how a healthcare coordinator improves the quality of care delivered in the community?
Serves as a bridge between patients, families, and other health care providers.
Care coordinators organize care provided by multiple providers that may not have the ability or means to communicate with each other. Coordinating care improves disease management and patient compliance, offers resources, and removes barriers.
A care coordinator collaborates with health care providers to ensure that a patient with a chronic health problem receives appropriate care, avoids hospitalization, and attends follow-up visits as scheduled.
For which reason should the healthcare coordinator use health information technology (HIT) to improve a patient's care?
It improves communication between clinicians and inpatient and outpatient healthcare settings.
HIT improves communication between multiple clinicians and clinical sites by improving access to the patient's medical and medication history, plan of care, referral history, and support services.
A care coordinator is scheduled to meet with adolescents and adult patients in a community clinic.
Which action could a healthcare coordinator take to demonstrates how care coordination improves in disease management?
Meet with the school nurse to review the action plans for students with asthma.
Care coordination interventions for patients with chronic diseases effectively link outreach, support services, education and guidance. Meeting with the school nurse to review the action plans for students with asthma ensures compliance with medication use and administration in a location convenient for the patient and care providers.
What are the outcome goals of the Ambulatory Integration of Medical and Social (AIMS) model?
To obtain patient engagement, identify a best practice care model, manage cases as a team, and identify the potential ongoing needs of the patient and family to maintain optimal health
The AIMS model goals are patient engagement, care plan development, case management, and ongoing care as needed.
What occurs during the patient engagement and assessment phases of the AIMS model?
The patient engagement and assessment phases occur during the initial introduction and detailed interview. This allows for the care coordinator and patient to build a trusting relationship and identify the goals and outcomes for care delivery, identify what part each team member will play in the ongoing care team, and identify any concerns that need to be addressed to improve the potential for meetings the goals of care delivery.
The introduction of the care coordinator to the care planning process, review of the aims of the team to facilitate optimal health, and incorporation of whatever considerations need to be addressed are vital to a quality outcome. The client and family should be actively engaged in the process.
What is the goal for the case management phase in the AIMS model?
The goals are about managing the care plan and ensuring that the goals of the plan are considered and modified as needed, and to offer support to the team, the patient, and the family for the success of the care delivery.
The care management phase is to evaluate the goals, modify the plan as needed, and to support the care team, patient, and family as needed to meet the goals of the AIMS model.
Under which step are there guidelines for the system navigator?
Step 3
Step 3 is where the Systems Navigator has specific guidelines for care planning.
Under which step are there care conference guidelines?
Step 2
Step 2 is where the client goals and needs are assessed and the care team members are identified.
Under which step is the Patient Post Card?
Step 1
Step 1 is when the identification and referral information is completed and tracked.
Under which step is the Coordinated Care Plan located?
Step 2
Step 2 is where the client goals and needs are assessed and the care team members are identified.
On which form could a patient sign and acknowledge his or her right to withdraw consent to sharing personal health information?
Participant Consent Form
The Participant Consent Form is used to received a patient consent to have his/her personal health information shared with HealthLink and providers of HealthLink.
On which form would the care coordinator document the pharmacies that a patient uses?
Coordinated Care Plan
The Coordinated Care Plan provides detailed patient information to create a higher user profile for HealthLink.
Which document explains to the patient what the patient will receive after the care plan meeting?
Patient Post Card
The Patient Post Card provides essential information to the patient regarding what is a Coordinated Care Plan and the type of consent needed for HealthLink.
Which form would be used to document criteria that validate the patient as a high user of the health system?
Coordinated Care Plan
The Coordinated Care Plan provides detailed patient information to create a higher user profile for HealthLink.
Which action should a healthcare coordinator complete when establishing a plan of care for the patient?
Identify the needs, access to resources, and support services.
.The case manager should identify the patient's strengths and barriers. This will assist with managing the appropriate plan of care for the patient.
Which action should the healthcare coordinator perform when coordinating a patient's care plan?
Facilitates services to provide ongoing supportive care.
Case management provides ongoing support and coordination of services to improve the patient's quality of life.
Which action will the healthcare coordinator take when coordinating care in a clinical setting?
Identifies strengths, barriers, and plans care.
The case manager assesses the patient's strengths and barriers, creates a plan of care, identifies and arranges the appropriate support services, and monitors for reevaluation or lack of compliance.
What is the term identified in the lesson for gathering information, engaging the patient and family, and building a trusting relationship?
Motivational interviewing
During the interviewing process, it is vital for the care coordinator to build a trusting relationship with the patient and family for collection of medical history and other pertinent information and to encourage the patient and family to engage in the planning of care coordination as members of the team.
What are the five key steps that should take place in communication skills needed for care coordination?
Setting the stage, eliciting information, providing information to the patient and family, understanding the patient and family's perspective, and ending the encounter
These five steps are a guide to completing a quality interview with the patient and family: setting the stage, eliciting the information, providing information to the patient and family, understanding the patient's perspective, and ending the encounter.
During the motivational interviewing session, what are some of the behaviors that demonstrate active listening?
Undivided attention, appropriate body language, acknowledgement of patient, nonjudgmental attitude, and respectful responses
Demonstrations of active listening are behaviors that convey attention and respect. Here are five that are recommended from the reading: undivided attention, appropriate body language, acknowledgement of patient, nonjudgmental attitude, and respectful responses.
Culturally competent care coordination teams tend to demonstrate the following key behaviors or approaches:
Collaborative relationship, effective communications, respectful care incorporating culture into care, holistic perspective, individualized care, interprofessional coordination, empowerment, and cultural skills
These practices are key descriptors of culturally competent care, including collaborative relationship, effective communications, respectful care incorporating culture into care, holistic perspective, individualized care, interprofessional coordination, empowerment, and cultural skills.
What are some of the factors that should be included for a patient's culturally competent care?
Age, ethnicity, geographical background, languages spoken, socioeconomic status, health literacy, and other factors
Culturally competent care accounts for the dimensions of a patient's background (e.g., age, ethnicity, geographical background, languages spoken, socioeconomic status, health literacy, etc.) in determining the approach to both care and healthcare plan coordination.
While working with an older individual, you ask that the family leave the room. After they leave, you notice the patient is anxious and not engaged in the conversation or responding verbally.
What are some considerations to evaluate for communicating with this patient?
Consider bringing the family back into the room.
Cultural sensitivity involves discussing with the patient and family who needs to be present during all discussions. Some cultures use a social system to identify the best treatment for older members of their society.
In which way should a healthcare coordinator collaborate with a patient's interdisciplinary team?
Share patient responses to care and treatment during the meeting.
An interdisciplinary team consists of all healthcare providers involved in the patient's care. It is a joint effort with all team members having the same common goal to meet the patient's needs. All members' assessments, treatments, and outcomes are taken into consideration and discussed during the meeting.
A healthcare coordinator is using motivational interviewing to counsel an adolescent with obesity.
In which way should they facilitate behavior change?
Encourages goals to change lifestyle and eating habits.
Motivational interviewing is a communication technique used to help identify therapeutic interventions that strengthening the patient's personal motivation and commitment to newly established treatment goals.
A healthcare coordinator is preparing to assess a patient from a non-English speaking culture.
In which way will they provide culturally appropriate care to this patient?
Honors the patient's choices and beliefs
When providing culturally appropriate care, the patient's personal and cultural preferences are identified and taken into consideration.
All of the data that were collected at the starting point for Charles's care coordination would have been initiated at what phase in the care coordination process?
Issue identification and collection of patient data begin after the completion of the case selection and intake into case management and occur intermittently, as needed, throughout the case.
The face-to-face meetings with the IEHP team represent which phase of the care coordination process?
This phase puts the case management plan into action, and these meetings with the care team allow members of the team to implement treatment interventions and track the patient's progress.
Identification of a plan to manage Charles's mental health issues and keep him from seeking hospitalization are part of which phase of the care coordination process?
During the development of the care plan, the care team establishes goals of the intervention and prioritizes the needs of the patient, support system, and family or caregiver, as well as determines the types of services and resources that are available in order to address the established goals or desired outcomes.
The "Health Building" aspects of Charles's care represent which phase of the care coordination process?
As the patient has progressed through the plan and is making progress on goals, new goals can be determined for monitoring.
The "Achieving Goals" outcomes of Charles's care represent which phase of the care coordination process?
Once a patient has established new patterns of behavior and has achieved treatment intervention goals, he or she may be eventually exited from the plan (while the care manager would still conduct periodic checks on the patient's ongoing progress).
As the care coordinator, a unique client case has you thinking about options for the family of a client with Alzheimer disease. The client is in an early stage and needs to be around others for safety reasons. The family is with the client most of the evening and at night but is not able to cover the daytime hours of 9 am to 5 pm.
What is a cost-effective consideration that will meet the needs of the client and family?
Look at community services for seniors.
The option of a senior center will allow the client to be engaged in activities outside of the family, yet allow the patient to have others close by without the cost of a personal sitter or healthcare worker. Most senior centers have staff available. The center should be made aware of the client's condition so that they can plan for safety concerns.
The client has some special needs that should be set up prior to discharge. Your organizations do not offer these types of services.
How will you facilitate getting the services established for the client?
Contact multiple community organizations that offer the services and seek information on the options and prices related to the services. Consider adding these services to your organization's partnership list for future utilization.
No organization can provide every service that may be needed. Partnerships with community organizations that are focused on providing specialized services to clients are vital to the success of both this client and other clients.
A special needs child and his family are ready to consider transitioning back to a home setting, but the care needed in the home would be too extensive for the family alone.
What would be the best option for this situation?
Review the admission assessment and interview to identify whether a home care situation was already in place. If not, work with the family to see if they would like to have you contact the hospital's home health department to arrange this service through the organization.
Collaboration with the client and family is vital to success. If they do not already have a service established or want to change services, the coordinator can contact the organization's services to attempt to cover it. Also have other services that are offered within the community available, so the family has multiple options. [Show Less]