WGU D116 Advanced Pharmacology Unit 5: Transition of Care & Care Coordination MASTERY GUIDE 2025 – 19 Expert-Curated Q&A with Clinical Rationales, Interprofessional Collaboration Strategies, and Patient Safety Protocols

What is polypharmacy?

A person takes multiple medications. Can be broken down into its roots: poly (multiple) and pharmacy (medications).

What is referred to as the prescribing cascade?

The process whereby drug side effects are misdiagnosed as symptoms of another problem, resulting in further prescriptions

Mrs. T has type 2 diabetes, cardiovascular disease, and a history positive for MI. The pharmacy calls you to inform you of a clear example of polypharmacy.

What is an example of polypharmacy?

The patient is taking multiple medications from multiple providers and probably needs to discontinue some of them.; The pharmacy and pharmacist are good resources to identify duplications in therapy and overprescribing from multiple providers.

he Joint Commission identified which of the following breakdowns as a contributor to ineffective transitions of care?

Lack of accountability; has outlined the root cause of ineffective transition of care to be lack of accountability.

Why is it important to collect medication histories as part of the medication reconciliation process?

It ensures a patient's medications remain accurate during transitions of care.

What is the main intended benefit of medication reconciliation?

To reduce negative outcomes resulting from medication errors and discrepancies; Reducing negative outcomes resulting from medication errors and discrepancies is the crux.

A 50-year-old female is brought to the emergency department in an unconscious state after having been in a motor vehicle accident. A coworker has accompanied the patient but does not know anything about her medications, just which pharmacy the patient goes to.

What is the most appropriate step to take in the medication reconciliation process at this point?

Call the pharmacy to obtain a medication list; This is where you will find the most comprehensive and updated list

What is the relationship between medication reconciliation and hospital readmissions?

Medication reconciliation in combination with other services may positively impact hospital readmissions in some institutions.Hospital readmissions are decreased when transitions of care are performed at a high level.

Medication reconciliation must be performed using a protocol approved by The Joint Commission.

The Joint Commission has recognized medication reconciliation as a National Patient Safety Goal, and they have developed elements of performance for medication reconciliation. These make for great guidelines. But using these measures is not required to perform medication reconciliation.

What is the primary focus of Transitional Care Management (TCM) programs according to the Centers for Medicare & Medicaid Services (CMS)?

Enhancing care coordination during healthcare transitions

Which of the following is NOT typically a component of a Transitional Care Management [TCM] program?

Medication reconciliation

Patient education on self-care management

Performing surgery after discharge

Coordination with post-discharge care providers

According to CMS guidelines, how soon after discharge from a hospital setting should a patient be contacted for initial Transitional Care Management [TCM] services?

Within 2 business days

The Institute for Healthcare Improvement [IHI]"Triple Aim" of healthcare is often mentioned in the context of Transitional Care Management [TCM]. What are the three aims?

Improved patient care, population health, and reduced costs

All of the following are standard interventions that should be implemented for a hospital inpatient who is at high risk for readmission except for:

Early identification of a primary caregiver to include in educational sessions

Using teachback with visual and written evidence-based teaching materials

Perform medication reconciliation upon admission

Scheduling all follow up appointments prior to discharge

Studies have shown that successful TCM programs often rely on collaboration between which healthcare professionals?

Nurse practitioners, physicians, and social workers

What is one of the biggest challenges to implementing effective TCM programs in today's healthcare landscape?

Lack of awareness about TCM benefits &

Difficulty in coordinating care across different providers

An 82-year-old patient with chronic heart failure and dementia is being discharged from the hospital to a skilled nursing facility (SNF) after a week-long stay for pneumonia treatment. The patient requires assistance with most activities of daily living (ADLs) and has a history of falls. According to CMS guidelines, which of the following actions is MOST important to ensure a smooth transition for this patient?

Ensuring a comprehensive discharge plan is communicated to the SNF staff, including medication reconciliation, fall risk assessment, and a plan for ongoing dementia management.

A 75-year-old patient with diabetes and recent amputation of their right leg is considering transitioning to a long-term care facility. The patient is independent with most ADLs but requires assistance with dressing and wound care for the amputation site. From a CMS perspective, which factor should be considered the HIGHEST priority when evaluating this patient's suitability for a long-term care placement?

The SNF's ability to provide appropriate wound care services and physical therapy for the patient's specific needs.

A 68-year-old patient with a history of stroke is medically stable after a hospital stay and is interested in returning home. However, the patient's spouse is unable to provide all the necessary daily support due to their own health limitations.When discussing long-term care options with this patient, which of the following statements is MOST aligned with CMS guidelines regarding patient-centered care?

"We should explore all available options, including home care with additional support services, to determine the most suitable environment that meets your individual needs and preferences."