Coordination of Care Quiz 1

The ultimate goal of effective care coordination is what?

Improving patient outcomes

What happens if a patient is readmitted within 30 days of discharge for the same diagnosis?

Second hospital stay might not be reimbursed, espeically if the hospital has a high readmission rate.

What action can medicare and medicaid take for hospitals with high readmission rates?

Fine them $$$

Three diseases with high preventable readmission rates

Myocardial infarction, CHF, pneumonia

What organization sets standards for hospital readmissions?

HRRP Hospital Readmission Reduction Program sets readmission targets and fines hospitals if they don't meet standards

Strategies to prevent CHF readmission

Patient education on diet, medication, evaluate external factors that may inhibit follow through with teaching

Strategies to prevent affordability issues with medication causing readmission

Verify coverage or costs up front and follow up afterwards

Who qualifies for Medicare?

adults > 65 years; ESRD; disability

Who qualifies for Medicaid?

Persons with insufficient income, pregnant women, children under 19, people who are blind, people who need nursing home care

Medicare Part A coverage

Covers hospital admission and provided free by government

Medicare Part B covergage

Covers services by healthcare provider, "doctor coverage" premium is deducted from pts social security check

Medicare Part D Coverage

Prescription drug coverage (D for Drug)

Medicare Part C Coverage

Private insurance + medicare (called medicare advantage plan)

Medicare Donut Hole (Coverage Gap)

Patient must pay until deductible is met, Medicare takes over until they hit their max payout, then the prices go back up for patients. Cycle restarts Jan 1

Medicaid program designed for low-income children

CHIP - Childrens health insurance program

For elderly low-income, how do medicare and medicaid interact?

Medicaid will cover Medicare premiums, deductibles, copays and Part D

Pro and con of private insurance?

Pro: Some employers cover part of cost making it affordable

Con: Without employer sponsorship it is very expensive

#1 Cause of bankruptcy in the US

Medical costs

Fee-for-Service Based Care

The more patients and services provided, the more money earned. NO INCENTIVES TO LIMIT COST OR KEEP PEOPLE HEALTHY

Value-based Care

payment to medical providers is based on patient outcomes, not quantity and complexity of services performed. Competition lowers cost.

What is the Triple AIM?

Improving the experience of care

Improving the health of populations

Reducing per capita costs of health care

Patient experience is captured or measured with what survey?

HCAHPS- Hospital Consumer Assessment of Healthcare Providers and Systems

Components of HCAHPS Survey

Communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, discharge information, overall hospital experience

Agency that reviews HCAHPS surverys

AHRQ - Agency for healthcare research and quality

Where are does AHRQ post the results from HCAHPS surveys?

Hospital Compare and Nursing Home Compare

What happens if hospitals receive low HCAHPS scores?

Decreased reimbursement from Medicare/Medicaid

Model used for effective communication among healthcare stakeholders

TeamSTEPPS

Technique for communicating critical information that requires immediate attention concerning a patient's condition

SBAR

Strategy used to communicate important or critical information during emergent situations

Call out. Ex. "Airway status?"

"Clear!"

Closed-loop communication technique used to ensure information is understood by the reciever

Check-back

Step 1. Sender initiates message

Step 2. Reciever accepts message and provides feedback

Step 3. sender double checks to ensure message is recieved

Strategy designed to enhance information exchange during transitions of care

Handoff- used I PASS THE BATON mneumonic

Short session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies...

Brief/Briefing

Ad hoc meeting to re-establish awareness and reinforce plans already established

Huddle; a meeting called to address a specific issue or situation

Informational exchange session designed to improve performance through discussing lessons learned and reinforcing positive behavior

Debrief

Situational Monitoring

Process of continually scanning and assessing what is going on around you to maintain situational awareness

Situational Awareness

Knowledge and understanding of your surroundings and situation

STEP Tool

□ S - State of the Patient

(patient history, vitals, meds, physical exam, plan of care, psychosocial status)

□ T - Team Members

(fatigue, workload, task performance, skill , stress)

□ E - Environment

(facility info, administrative info, human resources, triage acuity, equipment)

□ P - Progress Toward Goal

(status of team's patients, established team goals, tasks/actions of team, plan still appropriate)

Cross Monitoring

Monitoring actions of other team members, providing a safety net to watch each other's backs

I'M SAFE Checklist

Team members monitoring their own safety status

Illness

Medication

Stress

Alcohol and drugs

Fatigue

Eating and elimination

Feedback should be what specifically?

Timely, respectful, specific, directed toward improvement, considerate

Two Challenge Rule

Voice concern AT LEAST TWO TIMES to ensure safety concerns are addressed, utilize chain of command afterward

DESC Script

constructive approach for managing and resolving conflict

Describe the specific situation or behavior; provide concrete data

Express how the situation makes you feel/what your concerns are

Suggest other alternatives and seek agreement

Consequences should be stated in terms of impact on established team goals; strive for consensus

First Step of Nursing Process

Assessment

1. Identify patient needs barriers

2. Identify gaps in care

3. Ensure patient understands health status

Second step of nursing process

After assessment, treatment is based on diagnosis

Third Step of the Nursing Process

Identify complications - Certain diagnosis require specific teaching and measures before pt can be discharged.

High risk diagnosis for readmission

1. Pneumonia

2. MI

3. CHF

Fourth Step of Nursing Process

Planning outcomes:

Understand patient goals and preferences to prepare for the transition of their care. Have pt be active participant in this.

Fifth step of Nursing Process

Intervention - Nurse facilitates intervention or communication with facilities or providers to

Sixth Step of Nursing Process

Evaluate if the transition was effective and re-evaluate if needed

Does discharge planning end when the patient leaves the acute care facility?

No, for some reason

Project RED (Re-Engineered Discharge)

Tool focused on improving discharge planning and preventing readmission to hospitals. Each step of the discharge process is planned out with a system

Project BOOST

Focuses on transitional care of older adults. Includes training and toolkits for staff.