Deck 8: Transitional Planning Across the Continuum of Care

Question 1

Patients, especially the elderly, are most vulnerable when __________________.

A) Being admitted to a hospital
B) Entering an extended-care facility
C) Discharging from one facility to another
D) Living independently

Answer 1

Discharging from one facility to another

Question 2

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

A) Discharge planning
B) Deinstitutionalization
C) Gatekeeping
D) Person-centered planning

Answer 2

Discharge planning

Question 3

An interdisciplinary team differs from a transdisciplinary team because _____

A) Transdisciplinary teams have fluid professional boundaries.
B) Interdisciplinary teams have fluid professional boundaries.
C) Transdisciplinary teams are only assigned to the most difficult, complex patients.
D) Interdisciplinary teams are only assigned to the most difficult, complex patients.

Answer 3

Transdisciplinary teams have fluid professional boundaries.

Question 4

Dr. Johnson expressed frustration that the physician from a patient's insurance company did not agree with Dr. Johnson's plan of care. Dr. Johnson noted that the insurance company's physician did not practice the same area of medicine as Dr. Johnson and felt this should disqualify the insurance company's physician from acting as a _________________________. In Dr. Johnson's opinion, the insurance company's physician was unable to understand the rationale for Dr. Johnson's plan of care.

A) Performance evaluator
B) Administrator
C) Physician
D) Gatekeeper

Question 5

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

A) Medical
B) Medical home
C) Preferred provider

Question 6

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.

A) Gatekeeping
B) Preadmission planning
C) Transitional case management
D) Integrated care

Question 7

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.

A) Psychoeducational group notes
B) Advanced care directives
C) Discharge planning checklist
D)Preadmission planning checklist

Question 8

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 ___________________.

A) Low medical complexity, high functional ability, high social support/Low
B) Low medical complexity, low functional ability, low social support/Medium low
C) High medical complexity, high functional ability, high social support/Medium high
D) High medical complexity, low functional ability, low social support/High

Question 9

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 _________________.

A) Low medical complexity, high functional ability, high social support/Low
B) Low medical complexity, low functional ability, low social support/Medium low
C) High medical complexity, high functional ability, high social support/Medium high
D) High medical complexity, low functional ability, low social support/High

Question 10

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 _________________.

A) Low medical complexity, high functional ability, high social support/Low
B) Low medical complexity, low functional ability, low social support/Medium low
C) High medical complexity, high functional ability, high social support/Medium high
D) High medical complexity, low functional ability, low social support/High

Question 11

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 _________________.

A) Low medical complexity, high functional ability, high social support/Low
B) Low medical complexity, low functional ability, low social support/Medium low
C) High medical complexity, high functional ability, high social support/Medium high
D) High medical complexity, low functional ability, low social support/High

Question 12

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

A) 30
B) 60
C) 90
D) 7

Question 13

June was in the hospital for surgery to repair a broken hip. She is 92 years old and has lived alone since her husband died 2 years ago. She has eight children. Six of the children live locally and have said they can be available "some" to help out. They have put together a caregiving rotation, and someone can be with June every day for several hours, but no one can spend the night with June. June would like to go home if she can. You are getting ready to meet with June to discuss her options. What would be the best discharge option for June?

A) Skilled home health services
B) Home health services with an aide
C) Nursing home (ECF)
D) Adult foster care

Question 14

After meeting with June, the 92-year-old woman who broke her hip, you wonder if there is some alternative to a nursing home placement. You call the Area Agency that serves June's county and learn that the ______________________ list is open, and June does qualify for additional services in the home. You are pleased to present this new alternative to June, because she really wanted to return home at discharge.

A) Medicaid Waiver
B) Medicare Waiver
C) Community care
D) Respite care

Question 15

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.

A) Discharge planning checklist
B) Preadmission checklist
C) Nursing home checklist
D) Minimum data set

Question 16

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

A) 50%
B) 80%
C) 100%
D) 90%

Question 17

Robert's mother, Liza, has dementia. He has been able to care for Liza in his home, but he is worried he will no longer be able to care for her at home. He came home from work one day this week, and the front door was wide open. Liza had taken the dog out and forgot to close the door when she returned home. Robert meets with you to discuss placement options. After reviewing the fact that Robert is still able to care for his mother when he is home, Robert opts for ________________________.

A) Adult foster-care homes
B) Skilled home health
C) Continuing-care community
D) Adult day care

Question 18

Emma is an 85-year-old woman who lives alone in a small apartment. She has a small kitchenette but can also go to the dining room for meals if she wants. She values the independence she has but finds security in knowing there are other residents her age in the complex, as well as assistance with some services like cooking and laundry. Emma lives in a(n) ____________________.

A) Nursing home
B) Adult foster care
C) Assisted-living facility
D) Continuing care community

Question 19

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.

A) Adult day care centers
B) Continuing-care retirement communities
C) Nursing homes
D) Assisted-living facilities

Question 20

In some instances, family members can be hired by the patient to provide chore services via _____________________________.

A) Chore grants
B) Medicaid Waivers
C) OBRA
D) Adult day care centers

Question 21

One reason few hospitals use the RED model of discharge planning is that the cost to administer this program is not offset by additional money generated from readmissions.

Question 22

Under the DRG-based payment system, the fees for inpatient hospital care are "bundled" into a single fee for reimbursement.

Question 23

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

Question 24

Basic care, which is routine, custodial care in an extended-care facility, is paid for by Medicare, but only for the first 100 days.

Question 25

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

Question 26

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

Question 27

Adult foster care is usually covered by insurance.

Question 28

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

Question 29

__________________________ is determined on the basis of current diagnosis, prognosis, impact, and treatments required.

Question 30

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?

Question 31

Allison works as an inpatient social worker for a healthcare system. She assists with discharge planning. The healthcare system has its own home healthcare department, which Allison knows provides very good care. Allison automatically refers all her patients to this agency. After all, the patients have chosen to use the system for their inpatient care, the care offered by the home health department is fantastic, and it makes it easier to coordinate care because she is friends with most of the home health social workers. Is Allison practicing ethically? Why or Why not?

Question 32

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