Patient Care Coordination and Education

What is comprehensive care?

designed for the patient’s physical and mental health

What is patient-centered care?

patients and their families are the core team members

What is coordinated care?

provider-directed medical practice oversees all healthcare

What are accessible services?

tools provided through patient info web portals

What are quality and safety commitments?

delivering evidence-based medicine assessed by collecting safety data and patient satisfaction

What are Accountable Care Org’s (ACOs)?

group of professionals associated with a defined patient population that are accountable for the quality and cost of care

What is the main goal of a Primary Care Provider (PCP)?

coordinating preventive health care services

Why should information to patients be documented?

to promote continuity of care and ensure accurate record keeping

What are risk factors for blood pressure?

Black, overweight, family history, and previously recorded high blood pressure

When does breast cancer screening start?

age 40, then annually

When should cervical cancer screenings occur?

• every 3 years from ages 21-29

• every 3 or 5 yrs from ages 30 - 65

When should colorectal cancer occur?

starting at 45 using a FOBT

When should lung cancer screening occur?

ages 50-80 who have a 20-pack-year smoking history or quit within past 15 years

When should bone density screenings occur?

younger than 65

When should diabetes screening occur?

every 3 years for adults

What are risk factors for eye disease?

Black, diabetes, 40+ years, history of glaucoma

What vaccination should be given at birth?

Hepatitis B

When should each dose of Hepatitis B be given?

• 1st dose: birth

• 2nd dose: 1-2 months

• 3rd dose: 6-18 months

When should the first dose of Hib be given?

1-2 months

How often should the flu vaccine be given?

annually

When should abdominal aortic aneurysms be screened?

males aged 65-75 who have smoked

What are risk factors for Hepatitis C?

HIV, AIDS, born between 1945-1965, history of blood transfusions or organ transplant before 1992

When should HIV be screened?

ages 15-65

What are risk factors for HIV?

young children and older adults

What is considered drinking in moderation for women and men?

• women: 1 drink a day

• men: 2 drinks a day

What questions should be asked when screening for nicotine or tobacco use?

whether they’re used, what kind, how much per day, use history, and quitting behaviors

What is the purpose of screening for older adult safety?

screens for abuse and neglect

What is the purpose of clinical quality measures?

they identify treatments, processes, experiences, and outcomes

How is patient education documented?

indicate topic provider requested for coaching, materials, points covered, and questions and responses for the patient

What should be included in a community resource list?

name, address, web address, phone #, contact person

How often should a community resource list be updated?

every 6 months

How can immunizations be acquired if a patient has financial barriers?

send a referral to the local board of health to obtain immunizations affordably

What is TASH?

advocates for disability inclusion

What is the ARC?

develops programs, funding, and public policy assisting people with goals

When should follow-ups and medications be discussed?

after a patient encounter

What should a patient do if they want someone else to receive their health information?

sign a release form

Behavioral Barriers

diet, smoking, exercise

Biological Barriers

anemia, hemophilia, heart disease, cancer, cystic fibrosis

Environmental Barriers

opportunities for education and employment, transportation, access to foods, crime exposure

Physical barriers

natural environment on health

What is the referral process?

1. check if specialist will accept patient’s insurance

2. give patient the name and number of specialist

3. follow up to ensure patient has an appointment

What communicable disease should be reported to local agencies?

• TB

• e. coli

• foodborne diseases

• lyme disease

• Hepatitis except A

• HIV

• gonococcal infections

• COVID

What demographic does telehealth make more opportunities for?

rural areas