NURS 5462 COMPILED ACTUAL TEST
PAPER 2026 FULL ANSWERS GRADED A+
⩥ Guided Care.
Answer: Managing complex older adults in ambulatory care or home
care, and through transitions
Managing complex older adults in ambulatory care or home care, and
through transitions, Post-discharge: timely communication, timely clinic
follow-up, followup call, post-discharge hotline, home visit Transition:
coach, patient-centered discharge instructions, provider continuity
*ess home health services Reduced costly health care utilization
⩥ Interventions to Reduce Acute Care Transfers (INTERACT).
Answer: Minimize rehospitalization of nursing-home residents
Postdischarge/Transition: • Timely staff communication of change in
clinical status • Evidence-based clinical care pathways triggered by
changes in clinical status • Advance care planning Reduction in
readmission
⩥ Community-based Care Transitions Program (CCTP).
Answer: federal government's program to improve transitions of care of
Medicare beneficiaries - Since its implementation in 2011, CCTP has
shown declines in all-cause 30-day rehospitalizations and all-cause
hospitalizations
,⩥ DISCHARGE DESTINATIONS • Home with home-health care.
Answer: ➢ Works well for older adults requiring only intermittent
skilled services (nursing, PT, or speech therapy) ➢ Older adults with
one of these needs may also receive assistance under Medicare from OT,
medical social work, or home-health aides ➢ Medicare requires that
older adults receiving homehealth care be homebound
⩥ • Custodial care.
Answer: (eg, assisted living or "nursing home")
⩥ • Skilled-nursing facility (SNF).
Answer: ➢ Under Medicare, older adults in SNFs must need a skilled
service such as IV therapy, artificial nutrition and hydration, complex
wound care, ostomy care, or rehabilitation ➢ Medicare covers all or part
of SNF care for up to 100 days after a qualifying hospital stay ➢
Coverage stops earlier if treatment goals are met or the older adult no
longer demonstrates improvement
⩥ • Acute rehabilitation hospital.
Answer: ➢ For older adults with substantial rehabilitation needs and
considerable rehabilitation potential ➢ Many older adults are ineligible
because they cannot participate in 3 hours/day of intense therapy
⩥ • Long-term acute care.
, Answer: ➢ For the rare patient who requires prolonged hospital-level
care such as long-term mechanical ventilation, multiple IV medications,
parenteral nutrition, or complex wound care
⩥ THREE STEPS TO IMPROVE TRANSITIONS.
Answer: 1. Set expectations for both the sending and receiving provider
teams
2. Tailor communication strategies
3. Target specific processes
⩥ • Patient-Centered Medical Home (PCMH).
Answer: ➢ Each patient has an ongoing relationship with a personal
physician and participates in decision making ➢ Physician directed
medical practice, whereby, the practice adopts a "whole-person
orientation" and provides/arranges for all of the patient's health care
needs
⩥ • Accountable Care Organization (ACO).
Answer: Aims to manage the full continuum of care➢ Provider-led
organization ❖Large integrated delivery systems ❖Physician - hospital
organizations ❖Independent practice associations
Receive fee-for-service payments, if certain quality performance
measures are achieved, the ACO will share in the cost savings
PAPER 2026 FULL ANSWERS GRADED A+
⩥ Guided Care.
Answer: Managing complex older adults in ambulatory care or home
care, and through transitions
Managing complex older adults in ambulatory care or home care, and
through transitions, Post-discharge: timely communication, timely clinic
follow-up, followup call, post-discharge hotline, home visit Transition:
coach, patient-centered discharge instructions, provider continuity
*ess home health services Reduced costly health care utilization
⩥ Interventions to Reduce Acute Care Transfers (INTERACT).
Answer: Minimize rehospitalization of nursing-home residents
Postdischarge/Transition: • Timely staff communication of change in
clinical status • Evidence-based clinical care pathways triggered by
changes in clinical status • Advance care planning Reduction in
readmission
⩥ Community-based Care Transitions Program (CCTP).
Answer: federal government's program to improve transitions of care of
Medicare beneficiaries - Since its implementation in 2011, CCTP has
shown declines in all-cause 30-day rehospitalizations and all-cause
hospitalizations
,⩥ DISCHARGE DESTINATIONS • Home with home-health care.
Answer: ➢ Works well for older adults requiring only intermittent
skilled services (nursing, PT, or speech therapy) ➢ Older adults with
one of these needs may also receive assistance under Medicare from OT,
medical social work, or home-health aides ➢ Medicare requires that
older adults receiving homehealth care be homebound
⩥ • Custodial care.
Answer: (eg, assisted living or "nursing home")
⩥ • Skilled-nursing facility (SNF).
Answer: ➢ Under Medicare, older adults in SNFs must need a skilled
service such as IV therapy, artificial nutrition and hydration, complex
wound care, ostomy care, or rehabilitation ➢ Medicare covers all or part
of SNF care for up to 100 days after a qualifying hospital stay ➢
Coverage stops earlier if treatment goals are met or the older adult no
longer demonstrates improvement
⩥ • Acute rehabilitation hospital.
Answer: ➢ For older adults with substantial rehabilitation needs and
considerable rehabilitation potential ➢ Many older adults are ineligible
because they cannot participate in 3 hours/day of intense therapy
⩥ • Long-term acute care.
, Answer: ➢ For the rare patient who requires prolonged hospital-level
care such as long-term mechanical ventilation, multiple IV medications,
parenteral nutrition, or complex wound care
⩥ THREE STEPS TO IMPROVE TRANSITIONS.
Answer: 1. Set expectations for both the sending and receiving provider
teams
2. Tailor communication strategies
3. Target specific processes
⩥ • Patient-Centered Medical Home (PCMH).
Answer: ➢ Each patient has an ongoing relationship with a personal
physician and participates in decision making ➢ Physician directed
medical practice, whereby, the practice adopts a "whole-person
orientation" and provides/arranges for all of the patient's health care
needs
⩥ • Accountable Care Organization (ACO).
Answer: Aims to manage the full continuum of care➢ Provider-led
organization ❖Large integrated delivery systems ❖Physician - hospital
organizations ❖Independent practice associations
Receive fee-for-service payments, if certain quality performance
measures are achieved, the ACO will share in the cost savings
