Continuity of Care Exam 1

What are the three types of continuity of care?

Informational continuity, Management continuity, and Relational continuity.

What is informational continuity?

Accurate and timely sharing of client information across providers and settings.

What is management continuity?

A consistent plan of care maintained across healthcare settings.

What is relational continuity?

An ongoing therapeutic relationship between the client and healthcare providers.

What is systems thinking?

Examining how all parts of the healthcare system interact to influence outcomes.

What is the primary goal of continuity of care?

Coordinated, consistent, patient-centered care across time and settings.

What is the primary cause of errors during transitions of care?

Communication breakdown.

What are common barriers during transitions of care?

Language barriers, poor health literacy, transportation issues, lack of insurance, inadequate caregiver support, and poor communication.

When should discharge planning begin?

At admission.

What is the nurse's role in continuity of care?

Coordinate care, communicate information, make referrals, plan discharge, and support safe transitions.

What is managed care?

A healthcare system focused on cost containment, prevention, coordinated care, and efficient resource use.

What is patient-focused care?

Care organized around the patient's needs, preferences, values, and goals.

What is differentiated practice?

Assigning nursing responsibilities based on education, experience, and competency.

What are Diagnosis-Related Groups (DRGs)?

A reimbursement system that groups clients by diagnosis to standardize expected care, length of stay, and cost.

What is case management?

Coordinating care and resources across settings to improve outcomes and reduce fragmented care.

What is the role of a case manager?

Coordinate care, connect clients with resources, facilitate discharge planning, and track outcomes.

What are examples of referrals?

PT, OT, speech therapy, home health, hospice, social work, transportation services, meal programs, and support groups.

What should discharge teaching include?

Medications, diet, activity, wound care, follow-up appointments, provider contacts, equipment needs, and safety precautions.

What does IDEAL stand for?

Include, Discuss, Educate, Assess understanding, Listen.

What factors should be assessed for equitable discharge planning?

Transportation, housing, food access, medication affordability, insurance, language, health literacy, caregiver support, and internet access.

What is the main legal concern when a competent patient leaves AMA?

False imprisonment if the patient is prevented from leaving.

What should the nurse do when a patient wants to leave AMA?

Explain risks, notify the provider, obtain an AMA form if possible, provide teaching, and document.

What is competence?

A legal determination of decision-making ability made by a court.

What is capacity?

A clinical determination of a person's ability to understand and make healthcare decisions.

Who determines competence?

A court.

Who determines capacity?

A healthcare provider or clinician.

What are the four disaster triage categories?

Red (immediate), Yellow (delayed), Green (minor), Black (expectant/deceased).

What is ESI Level 1?

Requires immediate life-saving intervention.

What is ESI Level 2?

High-risk situation requiring rapid evaluation.

What is ESI Level 3?

Stable client requiring multiple resources.

What is ESI Level 4?

Stable client requiring one resource.

What is ESI Level 5?

Stable client requiring no resources.

What is autonomy?

The patient's right to make their own decisions.

What is beneficence?

Acting in the patient's best interest.

What is nonmaleficence?

The duty to do no harm.

What is justice?

Fair and equal treatment.

What is fidelity?

Keeping promises and commitments.

What is veracity?

Telling the truth.

When should an ethics committee be consulted?

During complex ethical conflicts involving treatment decisions, end-of-life issues, or disagreements among stakeholders.

What are common handoff communication tools?

SBAR, ISBAR, PACE, and I-PASS.

What are the goals of interprofessional communication?

Promote safety, improve continuity of care, reduce errors, and support collaboration.

What are the principles of community partnerships?

Shared power, shared goals, integrity, flexibility, and negotiation.

What is the referral process in healthcare?

Working relationship → Establish referral criteria → Resource exploration → Accept client's decision → Make referral → Facilitate referral → Evaluate outcome (WERAMFE).

What does the "W" in WERAMFE stand for?

Working relationship.

What does the "E" in WERAMFE stand for?

Establish referral criteria.

What does the "R" in WERAMFE stand for?

Resource exploration.

What does the "A" in WERAMFE stand for?

Accept client's decision.

What does the "M" in WERAMFE stand for?

Make referral.

What does the "F" in WERAMFE stand for?

Facilitate referral.

What does the final "E" in WERAMFE stand for?

Evaluate outcome.

What is the purpose of continuity of care documentation?

To ensure continuity of care across providers and settings.

Who are the main participants in healthcare systems?

Consumers, licensed providers, and unlicensed providers.

What are examples of healthcare settings?

Hospitals, homes, clinics.

What are examples of healthcare system financing?

Medicare, Medicaid, private insurance, self-pay.

What are examples of regulatory agencies in healthcare?

State boards of nursing, CMS, Joint Commission, public health agencies.

What should the receiving nurse assess upon a client's arrival after transfer?

The client's tolerance of the transfer and current status.

What are examples of client barriers to referrals?

Refusal of service, lack of transportation, financial limitations, cultural beliefs, fear of treatment, and language barriers.

What are the steps of Basic Life Support (BLS)?

Check responsiveness and breathing → Call for help → Get AED → Check pulse → Start compressions if no pulse.

What is the role of documentation in nursing?

Supports continuity of care and individualized care plans.

What is advocacy in nursing?

Supporting informed client choices and protecting client rights.

What is the nurse's accountability regarding delegation?

The nurse may delegate tasks but cannot delegate accountability.

What are the elements required to prove malpractice?

Duty owed, breach of duty, foreseeability of harm, breach caused potential harm, and actual harm occurred.

What is secondary prevention focused on?

Early detection and treatment of disease.

What does the Nurse Licensure Compact (NLC) allow?

A nurse to practice in multiple participating states using one multistate license.

What tasks should remain with the RN?

Assessment, teaching, evaluation, nursing judgment, planning, and care of unstable or complex clients.

What should be included in a discharge summary?

Nursing care plans, care summaries, and important patient information.

What does ABCDE stand for in a primary survey?

Airway, Breathing, Circulation, Disability, Exposure.

What does Medicare Part A cover?

Hospital stays, home health care, hospice care, and skilled nursing facility care.

What are the eight principles of person-centered care?

Access to reliable healthcare advice, trusted professionals, continuity of care, family involvement, clear communication, respect, information sharing, and participation in decisions.

What is a referral in nursing?

A formal request for another healthcare service or provider.

What nursing interventions improve adherence?

Assess risks, promote healthy behaviors, strengthen coping skills, and improve access to resources.

What are the components of a healthcare system?

Participants, settings, regulatory agencies, and financing.

Who are the main participants in healthcare systems?

Consumers, licensed providers, and unlicensed providers.

What is the difference between frostnip and frostbite?

Frostnip is cold exposure without tissue injury; frostbite involves tissue injury and white, waxy skin.

What safety measures help prevent falls in older adults?

Remove rugs and clutter, improve lighting, install grab bars, use nonskid mats, review medications, and use assistive devices.

What is nursing informatics?

The integration of nursing science, information science, and technology to improve patient care.

What is delegation in nursing?

Assigning a task to another team member while retaining accountability for the outcome.

What are the six core accountability areas in nursing?

Safety, health advocacy, accountability for resources, legal compliance, professional relationships, and nursing practice.

What is centralized decision-making?

A system where leaders at the top make most decisions.

What are examples of transitions in continuity of care?

Hospital to home, hospital to rehab, rehab to home health, and home to primary care provider.

What is the purpose of a living will?

To outline a person's wishes regarding medical treatment if they become unable to communicate.

What are graphic records and flow sheets used for?

Documenting information to support continuity of care.

What is Hospital at Home?

Hospital-level acute care delivered in the patient's home.

Benefits of Hospital at Home?

Improved patient experience, similar or better outcomes, similar or lower cost, and frees hospital beds.

Who is a good candidate for Hospital at Home?

Patients needing acute but stable care with a safe home environment and available support.

Who is NOT a good candidate for Hospital at Home?

Patients with unstable cardiac conditions, new MI, major arrhythmias, or those requiring ECMO/VAD support.

What is managed care?

A healthcare delivery model focused on cost containment, prevention, coordinated care, and efficient resource use.

Goals of managed care?

Improve quality, reduce costs, coordinate services, and promote prevention.

What is differentiated practice?

A staffing model that assigns responsibilities based on education, experience, and competency.

Why is differentiated practice used?

To maximize staff skills, improve efficiency, support delegation, and provide cost-effective care.

What is patient-focused care?

Care organized around the patient's needs, preferences, values, and goals.

What are components of patient-focused care?

Shared decision-making, cultural sensitivity, family involvement, and respect for patient preferences.

What is a direct assignment?

A nurse is assigned specific patients.

What is an area assignment?

A nurse is assigned a geographic area or section of a unit.

What is a group assignment?

Patients are assigned to teams or pods of healthcare workers.

What information should be included in transfer documentation?

Diagnosis, providers, demographics, current status, plan of care, recent progress, vital signs, medications, allergies, diet, activity orders, equipment needs, fall risk, code status, and family involvement.

What are the sending nurse's responsibilities during transfer?

Confirm bed availability, communicate transfer time, provide report, complete documentation, arrange transport, and account for belongings.

What are the first steps during admission?

Introduce yourself, identify the patient, assess language barriers, and explain your role.

What should be discussed during admission regarding advance care planning?

Advance directives and healthcare decision-making preferences.

What should the nurse assess during admission?

Baseline health status, medications, allergies, support systems, home environment, safety risks, and discharge needs.