Exam 8: Transitional Planning Across the Continuum of Care

All 50 states must follow the same guidelines when conducting OBRA nursing home screenings.

Jillian is a 19-year-old woman who was admitted to the critical care unit in diabetic crisis. Jillian has moved out of her family home and is living in a local shelter. Jillian did not graduate high school and is low intellectual functioning. She does not have any services in place, and her family has said they do not want anything more to do with her. Jillian has started an application for disability but has not yet completed it. Jillian states she has a boyfriend who will look out for her, but no one has come to visit Jillian while she has been in the hospital. Jillian is medically stable and ready for discharge. Jillian's medical complexity vs. functional ability is _________________________________, making her postdischarge risk _________________.

In the ____________ model, care is integrated across inpatient, outpatient, in-home, or nursing home settings via a physician-directed team.

Adult foster care is usually covered by insurance.

One benefit of home healthcare is the availability of 24-hour skilled home care.

Patient complexity relative to discharge-planning needs involves three dimensions: medical complexity, patient functional ability, and social support and resources.

An interdisciplinary team differs from a transdisciplinary team because _____

List three factors that contribute to complications after discharge that can easily be addressed.

More than 50% of residents of nursing homes are incontinent.

Audrey works for a community hospital. She is called down to the recovery area of the surgery department because there is a patient who has just had surgery but does not have alternative transportation home. It is not safe for the patient to drive after having received anesthetic. The patient has her car keys in her hand and is insisting that she be discharged. Audrey meets with the patient and calmly explains the safety risk to the patient, as well as potentially to other drivers. The patient becomes tearful but, working together, they are able to find a neighbor who can pick the patient up and drive her home. Audrey realizes that when staff is doing ________________________________ they should include questions about transportation.

Don is a 42-year-old male. Don was hospitalized for acute appendicitis. He is recovering well from his surgery and ready for discharge. Don is developmentally disabled and lives with his 63-year-old mother, who assists him with most of his ADLs. Don and his mother spend most of their time together at home. However, they do attend church every Sunday. Don's medical complexity vs. functional ability is _________________________________, making his postdischarge risk _________________.

The Omnibus Reconciliation Act of 1987 (OBRA) was enacted in response to the deinstitutionalization of many nursing home residents in the 1980s and 1990s. What is the purpose of OBRA?

You are working in a community hospital case management department. Part of your job is to assess patients postdischarge needs. You meet with your patient, Jerry. Jerry has been hospitalized due to a broken ankle that needs to be surgically repaired. Jerry is 38 years old, married, is employed as a banker, and attends a local church. Jerry is also on several sports teams, and he plays the bass in a band. Jerry's medical complexity vs. functional ability is _____________________________, making his postdischarge risk ___________________.

Medicare typically authorizes episodes of care in ______________ -day increments.

Jim lives in Vermont. His elderly parents live in Michigan. Jim worries that if they need help, he will not be immediately available. When Jim comes home for Christmas, he and his parents visit several __________________________. Jim likes the fact that there are different levels of care offered so his mother and father can stay together even if one becomes more debilitated than the other.

Transitional care planning historically has been referred to as _________________________, but this implies that the job is finished once the patient has left the facility.

Durable medical equipment (DME) may be covered by Medicare up to ________________.

The __________________________ is an interdisciplinary patient-assessment form that is used to justify nursing home care, to ensure that the patient's care is appropriate to his or her needs, and to gather data on the characteristics of nursing home patients.

Mary is a 70-year-old woman who was admitted for pneumonia. She has completed a round of IV antibiotics, is much better, and is ready to go home. In addition to the pneumonia, Mary has diabetes, high blood pressure, and arthritis. Mary is a retired university professor, and she lives in an assisted-living community that is affiliated with the university she worked for. Despite her health issues, Mary takes part in most of the programming available in her community and gets around well with the assistance of her walker. Mary states she is able to do so much still because she prioritizes what is important to her and then paces herself throughout the day. Mary's medical complexity vs. functional ability is _________________________________, making her postdischarge risk _________________.

Mandy works in a primary care office. One of her patients, Mrs. Dixon, was recently hospitalized. Mrs. Dixon comes to the office for a follow-up appointment. Mandy had been faxed Mrs. Dixon's _______________________________ by the inpatient hospital social worker, so she already has an understanding of services that have been set up for Mrs. Dixon.