Coordination of Care: Quiz #1

What is the Hospital Readmissions Reduction Program?

-A Medicare program that reduces payments to hospitals with higher-than-expected 30-day readmission rates. It encourages better discharge planning, care coordination, and patient education to prevent avoidable readmissions

-In simple terms: If a hospital has too many readmissions, Medicare pays them less

-This penalty applies to all Medicare inpatient payments, not just for specific conditions

-The reduction can be up to 3%

Which conditions/procedures are targeted under the CMS Hospital Readmissions Reduction Program (related to 30-day readmissions)?

-acute myocardial infarction (AMI)

-chronic obstructive pulmonary disease (COPD)

-heart failure (HF)

-pneumonia

-coronary artery bypass graft (CABG) surgery

-elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

Why is the Hospital Readmissions Reduction Program so significant?

-Before, hospitals were reimbursed under a "fee for service" model

-Now, under a "value-based care" model, CMS can hold hospitals more accountable to readmissions that are costly and avoidable

-This is especially true for the 30-day condition-specific readmission measures under HRRP

What is Medicaid?

-Medicaid is a joint federal and state program that, together with the Children's Health Insurance Program (CHIP), provides health coverage to over 77.9 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities

-Medicaid is the single largest source of health coverage in the United States

Who can be covered under Medicaid?

-In general: Individuals and families with limited income and resources or those with qualified disabilities

-More specifically: children (may be covered by CHIP), pregnant women, parents and caretakers of eligible children, seniors, and people with disabilities

-In states that "expanded" Medicaid under the Affordable Care Act, nearly all adults below a certain income level quality

-In non-expansion states, eligibility is stricter

Who is covered under Medicare?

-In general: Adults over 65 years old or people under 65 who have received Social Security Disability Insurance (SSDI) benefits for at least 24 months

-Also, people of any age with end-state renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) qualify

Who is eligible for private insurance?

-The general population who are not covered by government programs or who choose to supplement them

-Run by private health insurance companies

-Often employer-sponsored

-Can also be purchase through the Marketplace for those who are U.S. citizens or legal residents and generally not incarcerated

-For those with lower income, there are certain tax credits that can help with premium affordability

What is Dual Eligibility (Medicare AND Medicaid)?

-Dual Eligibility refers to individuals who qualify for both Medicare and Medicaid simultaneously

-In order to be covered by both entities, an individual must be enrolled in Medicare (usually due to age or disability) AND meet a state's low-income requirements for Medicaid

-In this situation, Medicare acts as the primary payer (paying for medical services first) and Medicaid acts as the secondary payer (covering costs Medicare doesn't, like deductibles, copays, and sometimes services like long-term nursing home care)

How is Medicare structured?

-Medicare is structured into "Parts"

-Includes Parts A, B, C, and D

-Each Part covers different services

What is Medicare Part A?

-AKA "Hospital Insurance"

-Think of this as "room and board" in a clinical setting

-Covers inpatient hospital states, skilled nurse facility care, hospice care, and home health care

-Most people do not pay a monthly premium for Part A because they paid Medicare taxes while working, but there is a deductible if hospitalized

What is Medicare Part B?

-AKA "Medical Insurance"

-Think of this as "outpatient services" or the things that happen outside of a hospital bed

-Covers provider visits (primary care and specialists), outpatient care (imaging, lab tests, mental health screenings), preventive services (flu shots, cancer screenings, wellness visits), and durable medical equipment (wheelchairs, walks, oxygen tanks, etc.)

-Everyone pays a monthly premium (~$202 in 2026), and it typically covers 80% of costs, leaving 20% of payments out of pocket

What is Medicare Part C?

-AKA "Medicare Advantage"

-This is the "all-in-one" alternative that is not a separate benefit added to Parts A and B

-You sign up with a private company (like UnitedHealthcare, Humana, Aetna) to manage your Medicare benefits

-It must cover everything covered in Parts A and B and it usually includes Part D (which is prescription drug coverage)

-It often includes benefits that Parts A and B (Original Medicare) does not cover, like dental, vision, and hearing

-As a trade-off: You often have to use a specific network of doctors and receive prior authorizations for services

What is Medicare Part D?

-AKA "Prescription Drug Coverage"

-It covers prescription medications at the pharmacy (retail)

-These are plans run by private insurance companies approved by Medicare

-Original Medicare (Parts A and B) generally does not cover prescription drugs, so you must by a Part D plan separately unless you have a Medicare Advantage plan (Part C)

What is a the Medicare mnemonic (ABCD)?

-Admitted (inpatient)

-Basic care (doctors/outpatient)

-Combined (A + B + usually D)

-Drugs

What is Medigap?

-AKA "Medicare Supplement Insurance"

-This is a private insurance policy designed to pay for the "gaps" in cost that Parts A and B leaves for you to pay

-When you use Original Medicare, the government pays a large share of the bill, not not all of it (usually 80/20 split)

-This is risky because there is no limit on the 20% out-of-pocket cost (example: for a surgery is $100,000, the out-of-pocket cost would be $20,000)

-Medigap primarily covers financial costs, not extra medical services

-It typically pays for/can pay for the 20% cost-sharing, Part A deductible (and some older plans the Part B deductible, too), 80% of emergency care costs traveling outside of the U.S., and excess charges (charges more than the standard Medicare rate)

-It does not cover things like pharmacy prescriptions (Part D is required for this), custodial care in a nursing home, and vision/hearing/dental benefits

-Medigap plans are standardized by the federal government and identified by letters (ex: Plan A, Plan G, Plan N)

What is the "Golden Rule" about Medicare Advantage (Part C) and Medigap?

-You cannot have both at the same time

-You have two choices: Original Medicare (Parts A and B) + Part D + Medigap OR Medicare Advantage (Part C), which bundles everything but restricts network of providers

-Medigap is more expensive monthly than Medicare Advantage, but it gives the most freedom (see any doctor in the U.S. that accepts Medicare) and the least surprise costs (bills are almost always $0 after the premium)

What was the "donut hole" in Medicare Part D (eliminated for Medicare beneficiaries as of 2025)?

-Historically, Medicare Part D had a confusing four-stage structure, and the "donut hole" was the third stage

-It was set up like so: 1. Deductible is paid by 100% by the beneficiary, 2. The beneficiary pays a copay, and the plan pays the rest of the cost, 3. Donut hole: Once the beneficiary and the plan spent a certain total amount, the plan's coverage stopped OR dropped significantly, and the beneficiary had to pay a much higher percentage of prescription drug costs until they reached the "Catastrophic Coverage" phase, and 4. Once the Catastrophic Coverage kicks in, beneficiary pays very little (around 5% usually)

-This was a problem for people with expensive chronic conditions who would hit the "hole" mid-year, making medication adherence difficult

What was the new solution for the previous donut hole in Medicare Part D?

-The Inflation Reduction Act simplified the structure for Part D, so the donut hole was closed

-The new design is three stages: 1. Deductible: the beneficiary pays 100% until the deductible is met, 2. Initial Coverage: The beneficiary pays 25% coinsurance (or a set copay), and 3. Once out-of-pocket spending hits $2,000, the beneficiary pays $0 for the rest of the year

-Patients can also opt to spread the $2,000 out over the remaining months of the year into monthly bills rather than paying the cost all at once (to help make it more affordable for seniors)

Chapter 1 Summary of Nursing Informatics and the Foundation of Knowledge

Chapter 1: Nursing Science and Concepts of Knowledge

-This chapter establishes the theoretical groundwork for the book by introducing the Foundation of Knowledge model. This model serves as the organizing framework for the text, illustrating the dynamic interplay between four key concepts: Knowledge Acquisition, Knowledge Processing, Knowledge Generation, and Knowledge Dissemination.

-Nursing Science: Defined as the ethical application of knowledge acquired through education, research, and practice. It focuses on providing services and interventions to maintain, enhance, or restore patient health.

-The Nurse as a Knowledge Worker: Nurses are identified as "knowledge workers" who actively acquire, process, generate, and disseminate information to advance the nursing profession. This role is central to nursing informatics.

-Knowledge & Wisdom: The chapter explores the relationship between data, information, knowledge, and wisdom, emphasizing how nursing informatics manages and communicates these elements in practice.

Chapter 1 Key Definitions from Nursing Informatics and the Foundation of Knowledge

-Nursing Science: The ethical application of knowledge acquired through education, research, and practice to provide services and interventions to patients to maintain, enhance, or restore their health and to acquire, process, generate, and disseminate nursing knowledge to advance the nursing profession.

-Foundation of Knowledge Model: A theoretical framework used to understand how knowledge is created and used. It proposes that humans are organic information systems who constantly acquire, process, generate, and disseminate information or knowledge in both their professional and their personal lives. The model consists of four key concepts:

-Knowledge Acquisition: The act of getting knowledge.

-Knowledge Processing: The activity of processing data and information to create knowledge.

-Knowledge Generation: The creation of new knowledge by changing and evolving knowledge based on one's experience, education, and input from others.

-Knowledge Dissemination: Distribution and sharing of knowledge.

-Knowledge Worker: A person who works with information and generates information and knowledge as a product.

-Data: Raw facts that lack meaning.

-Information: Data processed using knowledge or data made functional through the application of knowledge.

-Knowledge: The awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision.

-Wisdom: The ability to act appropriately; it assumes actions directed by one's own wisdom. Wisdom uses knowledge and experience to heighten common sense and insight to exercise sound judgment in practical matters.

Chapter 2 Summary of Nursing Informatics and the Foundation of Knowledge

Chapter 2: Introduction to Information, Information Science, and Information Systems

-This chapter focuses on the "Information" building block, defining what information is and how it is managed through systems.

-Data vs. Information: It distinguishes between raw data (facts) and information (processed data with meaning). It emphasizes that for information to be valuable, it must be accurate, timely, and accessible.

-Information Science: Introduced as the study of how information is generated, collected, organized, stored, retrieved, and disseminated. It serves as a bridge between the technical aspects of systems and the user's needs.

-Information Systems (IS): The chapter describes the components of information systems (hardware, software, networks, and users) and their role in healthcare. It covers the cycle of input (data acquisition), processing (retrieval/analysis), and output (reports/documents).

Chapter 2 Key Definitions from Nursing Informatics and the Foundation of Knowledge

-Information Science: The science of information, studying the application and usage of information and knowledge in organizations and the interfacing or interaction between people, organizations, and information systems.

-Information System (IS): The manual and/or automated components of a system of users or people, recorded data, and actions used to process the data into information for a user, a group of users, or an organization.

-Information Processing: The retrieval, analysis, or synthesis of data.

-Computer-Based Information System: Combinations of hardware, software, and telecommunications networks that people build and use to collect, create, and distribute useful data, typically in organizational settings.

-Data Integrity: Refers to whole, complete, correct, and consistent data.

-Data Acquisition (Input): The activity of collecting and acquiring raw data.

-Output (Dissemination): Produces helpful information, which can be in the form of reports, documents, summaries, alerts, or outcomes.

-Feedback: Reactions to the inputting, processing, and outputting.

Chapter 3 Summary of Nursing Informatics and the Foundation of Knowledge

Chapter 3: Computer Science and the Foundation of Knowledge Model

This chapter examines the "Computer Science" building block, detailing the technology tools that facilitate the management of information.

Computer System Components: It provides an overview of essential computer hardware (processors, memory, input/output devices) and software (operating systems, productivity applications).

Managing Information: The computer is presented as a primary tool for nurses to manage data and generate knowledge. It explains how computer systems support collaboration and information exchange.

Emerging Technologies: The chapter touches on modern computing concepts such as cloud computing, mobile computing, and virtual reality (VR), discussing their impact on nursing practice and education. It also introduces the concept of the metaverse and its potential future role in healthcare.

Chapter 3 Key Definitions from Nursing Informatics and the Foundation of Knowledge

-Computer Science: Branch of engineering (application of science) that studies the theoretical foundations of information and computation and their implementation and application in computer systems.

-Central Processing Unit (CPU): The computer component that actually executes, calculates, and processes the binary computer code instigated by the operating system and other applications on the computer.

-Input Devices: Combinations of hardware, software, and telecommunications, including keyboards, light pens, touch screens, mice or other pointing devices, automatic scanners, and machines that can read magnetic ink characters or lettering.

-Output Devices: Combinations of hardware, software, and telecommunications and include sound and speech synthesis outputs, printers, and monitors.

-Cloud Computing: Web browser-based logon-accessible data, software, and hardware; could link systems together and reduce costs.

-Virtual Reality (VR): A three-dimensional, computer generated environment which can be explored and interacted with by a person.

-Haptics: The science of applying tactile sensation or touch to human-computer interactions.

-Metaverse: The evolution of the latest frontier of the internet that is continuously accessible and available, trisecting artificial intelligence (AI), the realities (mixed reality [MR]: augmented reality [AR] through virtual reality [VR]), and our psychosocioeconomic digital and physical presence.

What is an example of applying data, information, knowledge, and wisdom to care planning?

-Example: A patients BP is 185/95

-Information: Recognizing this BP is significantly elevated

-Knowledge: Combining the elevated BP with the patient's history of hypertension and missed morning medications

-Wisdom (Planning Care): Deciding to hold the patient's physical therapy session, administer prescribed PRN antihypertensive medication, and educate the patient on medication adherence

What is the Triple Aim of value-based healthcare?

-A triad of three components that defines the purpose of value-based care: (1) improve patient experience of care, (2) improve population health, and (3) lower the per capita cost of healthcare

-Measuring costs-savings efforts is easy, but measuring quality and patient experience is a little more complex

-To achieve these goals, organizations are designing new care delivery systems that center on individual and community needs and reward high-quality care with desired health outcomes

What is AHRQ?

-The Agency for Healthcare Research and Quality

-A federal agency within the Department of Health and Human Services (HHS)

-Focuses on improving healthcare quality, safety, efficiency, and effectiveness

-Key source of funding for health services research and produces resources to reduce medical errors and improve patient safety

What is the CAHPS Adult Hospital Survey (HCAHPS Survey)?

-The HCAHPS Survey is a national, standardized, publicly-reported survey of patient's perspectives of hospital care

-Made up of 32 items to allow for data collection and valid comparisons between hospitals (there is also a separate survey to evaluate home health organizations!)

-Originally survey began in 2006 with public reporting of scores made available in 2008

-Since 2012, these scores have played a role in hospital payment (by CMS) through the Hospital Value-Based Purchasing (VBP) Program, which went away with provider reimbursement based on service volume provided → incentivizing hospitals to improve quality and safety of care provided to CMS patients

-Important changes were made to the survey in 2025

How does the HCAHPS Survey work?

-Captures patient's experience of communication with doctors and nurses, restfulness of hospital environment, care coordination, responsiveness of staff, communication about medications, discharge information, cleanliness, symptoms, overall rating, and recommendation

-It's administered 2-42 days post-discharge to a random sample of adult patients

-Over 4,400 hospitals participate in the survey and it is completed by roughly two million patients annually

How is the HCAHPS Survey data used?

-Data collected from the survey is publicly reported and based on four consecutive quarters of results

-Data is published quarterly on the Medicare.gov Compare website and in the Data Catalog on Data.CMS.gov

What kind of questions are asked regarding nurses and doctors under the HCAHPS Survey?

-All questions as asked based on an "Always, Usually, Sometimes, Never, N/A" scale

-During this hospital stay, how often did nurses treat you with courtesy and respect?

-During this hospital stay, how often did nurses listen carefully to you?

-During this hospital stay, how often did nurses explain things in a way you could understand?

-During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted?

-During this hospital stay, how often did doctors treat you with courtesy and respect?

-During this hospital stay, how often did doctors listen carefully to you?

-During this hospital stay, how often did doctors explain things in a way you could understand?

Why are mutual respect and shared decision-making important when communicating about effective transitions of care?

-Helps ensure patient-centered care

-Improves adherence and health outcomes

-Fosters effective inter professional teamwork among providers

When does discharge planning and the transitions of care begin for hospitalized patients?

Discharge planning and transitions of care begin upon patient admission (or before admission for planned procedures)

Who should be involved in discharge planning?

-Patients and their families/caregivers → a team isn't a team without the patient!

-Registered nurses/care coordinations

-Physicians and mid-level providers

-Social workers/case managers

-Allied health professionals (pharmacy, PT/OT)

What is SBAR, and what are its four components?

-SBAR is a standardized framework for the healthcare team to communicate information to one another

-Situation: What is going on with the patient?

-Background: What is the clinical background or context?

-Assessment: What do I think the problem is?

-Recommendation: What would I recommend?

-Can also be known as I-SBAR, with I = Introduction

What is the difference between Situation and Background in SBAR?

-Situation is the "Breaking News" headline → it's the reason you are picking up the phone or giving the handoff right now

-Background is the "Story So Far" → it provides the relevant history and context that led up to this exact moment so the listener understands the patient's baseline

-If it just happened → Situation

-If it was already true → Background

What is an example of SBAR?

-Situation (The "Right Now"): "Hello Dr. Chen, this is Alex, the nurse caring for Mr. Davis in room 412. I am calling because Mr. Davis has just developed a sudden onset of left-sided weakness, slurred speech, and a facial droop that started about 15 minutes ago."

-Background (The "How We Got Here"): "Mr. Davis is a 72-year-old male who was admitted two days ago for observation following a minor concussion. His baseline neurological assessments have been completely normal and stable since admission. He has a past medical history of hypertension and atrial fibrillation, and his last dose of his anticoagulant was yesterday morning."

-Assessment (Your Clinical Judgment): "His current vitals are BP 185/95, HR 110 and irregular, RR 18, O2 97% on room air. Based on his sudden left-sided deficits and history of A-fib, I am concerned he is experiencing an acute ischemic stroke."

-Recommendation (What You Need): "I recommend he be evaluated immediately, and I believe we should activate a stroke code and get a stat CT."

What are best practices for shift handoff?

-Proper handoffs include the transfer of responsibility/accountability, clarity of information, verbal communication of information, acknowledgment by receiver, and opportunity to review

-Continuity of care should be maintained, medications should be reviewed, discuss pain management

What is TeamSTEPPS?

-AKA "Strategies & Tools to Enhance Performance and Patient Safety"

-An evidence-based framework to optimize team performance across the healthcare delivery system

-Based on team structure and four teachable learning skills: Communication, Leadership, Situation Monitoring, and Mutual Support

-Five key principles include: Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support

What is I PASS the BATON (related to TeamSTEPPS)?

-A tool to help provide a structured handoff developed by AHRQ

-Introduction: Introduce yourself and your role/job (include patient)

-Patient: Include name, identifiers, age, sex, and location

-Assessment: Present chief complaint, vital signs, symptoms, and diagnosis

-Situation: Current status, circumstances including code status, level of uncertainty, recent changes, and treatment response

-Safety: Concerns including critical lab values/reports, socioeconomic factors, allergies, alerts, falls, isolation, etc.

-Background: Comorbidities, previous episodes, current medications, family history

-Actions: What actions were taken or required? Provide rationale

-Timing: Level of urgency, explicit timing, and prioritization of actions

-Ownership: Who is responsible? Includes the patient/family

-Next: What will happen next? Anticipated changes? Plan?

Why is mutual support important in TeamSTEPPS?

It fosters a culture of safety, reduces errors, and prevents burnout by enabling team members to proactively manage workloads and share responsibility

What is CUS (related to TeamSTEPPS)?

-A framework of assertive statements that help empower team members to speak up if they sense or discover an essential safety concern

-Includes: "I am Concerned!" "I am Uncomfortable!" and "This is a Safety issue!"

What is DESC (related to TeamSTEPPS)?

-A constructive approach for managing and resolving conflict

-Describe the specific situation or behavior and 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

What is Project RED?

-AKA the "Re-Engineered Discharge Toolkit" funded by the AHRQ

-Developed at Boston University Medical Center

-Focused on improving the process of discharge planning and preventing readmission to the hospital

-Resulted in 30 percent fewer hospital readmissions and emergency room visits

-Tool that uses a clear system for educating the patient, making follow-up appointments, giving written discharge instructions, and following up after discharge with a phone call

-Setting expectations for each discharge helps avoid missing key elements

What is Project BOOST?

-AKA "Better Outcomes by Older adults through Safe Transitions" → updated to "Better Outcomes by Optimizing Safe Transitions" (now includes a pediatric version)

-Developed by the Society of Hospital Medicine

-Similar to Project RED but originally focused on transitional care of older adults

-Both Project RED and Project BOOST include training for staff in hospitals that adopt the toolkits

What is the registered nurse's general responsibility for care coordination according to professional standards?

The RN is responsible and accountable for establishing partnerships, communicating, and advocating for care coordination focused on the patient, their family, and support systems to deliver safe, quality care

According to the ANA Standard of Practice 5A: Care Coordination, what specific competencies must the RN demonstrate when coordinating care?

-Organizes the components of the plan

-Collaborates with the consumer to help manage health care based on mutually agreed upon outcomes

-Manages a healthcare consumer's care in order to reach mutually agreed upon outcomes

-Engages health care consumers in self-care to achieve preferred goals for quality of life

-Assists the health care consumer to identify options for care

-Communicates with the healthcare consumer, interprofessional team, and community-based resources to effect safe transitions in continuity of care

-Advocates for the delivery of dignified and holistic care by the interprofessional team

-Documents the coordination of care

What is the AHRQ's definition of Care Coordination?

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health services. Organizing care involves the marshalling of personnel and other resources needed to carry out all the required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. (McDonald et al., 2014, p. 6)