WGU D046 Intro to Care Coordination Final
Exam 2023 With Correct Answers as per the
Marking scheme
A patient arrives at your organization and needs specific care. Recently, your
organization signed an agreement with a university health system to allow for
telehealth assessment and identification of potential treatment options.
As the coordinator for this patient, what would be the next step to determine if this is a
good solution?
Correct answer- Contact the leadership team and the telehealth informatics specialist to
identify whether everything is in place for this patient to receive care through this
association.
Telehealth initiatives have associated a lot of organizations with university and other
larger health systems to facilitate a collaborative practice for care delivery.
A patient is ready to go home, and the family has expressed concern about the patient
being on her own during the day. The patient is unable to complete full activities of daily
living due to a recent injury.
Is there something that the coordination team can recommend for provision of lunch or
dinner?
Correct answer- Recommend that the family contact the local Meals on Wheels
program, so they can ensure the patient has access to food and drink during the day.
The patient has some activities for daily living but is not able to complete all activities.
Since the concern is around food during the day, the coordinator identified a service
that provides free or reduced delivery of hot meals one time a day. Use of this service
also provides reassurance for the family that someone has checked on the patient that
day.
The care team has determined that to reverse behaviors of smoking, a patient and
family should seek ongoing support.
What recommendations would the care coordinator make?
Correct answer- The care coordinator recommends current community outreach
programs available and assists the patient and family in deciding which option will meet
their needs.
The care coordinator should have a list of partners in the community who can assist
patients and families, encouraging compliance and promoting health wellness.
Provide an example of the clinic-clinician patient relationship.
Correct answer- Examples of the clinic-clinician patient relationship include trust
between the clinician and patient, shared decision-making, and mechanisms for mutual
support of patient self-management.
Provide an example of the clinic-clinician-community resource relationship.
Correct answer- Examples of the clinic-clinician-community resource relationship
include the level of interrelationship along Himmelman's continuum for collaborative
,WGU D046 Intro to Care Coordination Final
Exam 2023 With Correct Answers as per the
Marking scheme
processes, formal mechanisms for referrals, and effective mechanisms for feedback
from community resource to clinic.
Provide an example of the patient-community resource relationship.
Correct answer- Examples of the patient-community resource relationship include
patients' perception and trust of the community resource, formal mechanisms for
referrals, and effective communication between patient and community resource.
Using health technology to gather patient-specific data in their electronic health record,
how could the care coordination team focus care on an individual patient?
Correct answer- Using the data collected provides a collection of problems and
diagnosis-related groups (DRGs) that can help the care team determine discharge
needs. Review of demographic data can provide information after validation that
the information is correct during the assessment phase of contact with the patient
and family.
The electronic health record is a tool used by the coordination team and others to
gather information on what is going on with the patient, by providing information on
both the current situation and the medical history. It can also include advance directive
information for the future.
Where should the documentation of the care plan be recorded?
Correct answer- In the care planning module of the electronic health record
The electronic health record is where all the care team members have access to the
record of the patient, and it is the official health record for that patient.
A pregnant client is living in the wilds of Alaska. She is not considered to be high risk
and there is no reason for her to stay close to town since a frontier midwife is available
to travel to her home every month.
What would the care coordinator recommend for the client?
Correct answer- Satellite telecommunications device
A satellite phone is recommended to ensure that if any questions arise when the
midwife is not available, the client can call for help.
Which statement describes how a healthcare coordinator improves the quality of care
delivered in the community?
Correct answer- Serves as a bridge between patients, families, and other health care
providers.
Care coordinators organize care provided by multiple providers that may not have the
ability or means to communicate with each other. Coordinating care improves disease
management and patient compliance, offers resources, and removes barriers.
A care coordinator collaborates with health care providers to ensure that a patient with a
chronic health problem receives appropriate care, avoids hospitalization, and attends
follow-up visits as scheduled.
For which reason should the healthcare coordinator use health information technology
(HIT) to improve a patient's care?
, WGU D046 Intro to Care Coordination Final
Exam 2023 With Correct Answers as per the
Marking scheme
Correct answer- It improves communication between clinicians and inpatient and
outpatient healthcare settings.
HIT improves communication between multiple clinicians and clinical sites by improving
access to the patient's medical and medication history, plan of care, referral history, and
support services.
A care coordinator is scheduled to meet with adolescents and adult patients in a
community clinic.
Which action could a healthcare coordinator take to demonstrates how care
coordination improves in disease management?
Correct answer- Meet with the school nurse to review the action plans for students with
asthma.
Care coordination interventions for patients with chronic diseases effectively link
outreach, support services, education and guidance. Meeting with the school nurse to
review the action plans for students with asthma ensures compliance with medication
use and administration in a location convenient for the patient and care providers.
What are the outcome goals of the Ambulatory Integration of Medical and Social (AIMS)
model?
Correct answer- To obtain patient engagement, identify a best practice care model,
manage cases as a team, and identify the potential ongoing needs of the patient and
family to maintain optimal health
The AIMS model goals are patient engagement, care plan development, case
management, and ongoing care as needed.
What occurs during the patient engagement and assessment phases of the AIMS
model?
Correct answer- The patient engagement and assessment phases occur during the
initial introduction and detailed interview. This allows for the care coordinator and
patient to build a trusting relationship and identify the goals and outcomes for care
delivery, identify what part each team member will play in the ongoing care team, and
identify any concerns that need to be addressed to improve the potential for meetings
the goals of care delivery.
The introduction of the care coordinator to the care planning process, review of the aims
of the team to facilitate optimal health, and incorporation of whatever considerations
need to be addressed are vital to a quality outcome. The client and family should be
actively engaged in the process.
What is the goal for the case management phase in the AIMS model?
Correct answer- The goals are about managing the care plan and ensuring that the
goals of the plan are considered and modified as needed, and to offer support to the
team, the patient, and the family for the success of the care delivery.
The care management phase is to evaluate the goals, modify the plan as needed, and
to support the care team, patient, and family as needed to meet the goals of the AIMS
model.
Exam 2023 With Correct Answers as per the
Marking scheme
A patient arrives at your organization and needs specific care. Recently, your
organization signed an agreement with a university health system to allow for
telehealth assessment and identification of potential treatment options.
As the coordinator for this patient, what would be the next step to determine if this is a
good solution?
Correct answer- Contact the leadership team and the telehealth informatics specialist to
identify whether everything is in place for this patient to receive care through this
association.
Telehealth initiatives have associated a lot of organizations with university and other
larger health systems to facilitate a collaborative practice for care delivery.
A patient is ready to go home, and the family has expressed concern about the patient
being on her own during the day. The patient is unable to complete full activities of daily
living due to a recent injury.
Is there something that the coordination team can recommend for provision of lunch or
dinner?
Correct answer- Recommend that the family contact the local Meals on Wheels
program, so they can ensure the patient has access to food and drink during the day.
The patient has some activities for daily living but is not able to complete all activities.
Since the concern is around food during the day, the coordinator identified a service
that provides free or reduced delivery of hot meals one time a day. Use of this service
also provides reassurance for the family that someone has checked on the patient that
day.
The care team has determined that to reverse behaviors of smoking, a patient and
family should seek ongoing support.
What recommendations would the care coordinator make?
Correct answer- The care coordinator recommends current community outreach
programs available and assists the patient and family in deciding which option will meet
their needs.
The care coordinator should have a list of partners in the community who can assist
patients and families, encouraging compliance and promoting health wellness.
Provide an example of the clinic-clinician patient relationship.
Correct answer- Examples of the clinic-clinician patient relationship include trust
between the clinician and patient, shared decision-making, and mechanisms for mutual
support of patient self-management.
Provide an example of the clinic-clinician-community resource relationship.
Correct answer- Examples of the clinic-clinician-community resource relationship
include the level of interrelationship along Himmelman's continuum for collaborative
,WGU D046 Intro to Care Coordination Final
Exam 2023 With Correct Answers as per the
Marking scheme
processes, formal mechanisms for referrals, and effective mechanisms for feedback
from community resource to clinic.
Provide an example of the patient-community resource relationship.
Correct answer- Examples of the patient-community resource relationship include
patients' perception and trust of the community resource, formal mechanisms for
referrals, and effective communication between patient and community resource.
Using health technology to gather patient-specific data in their electronic health record,
how could the care coordination team focus care on an individual patient?
Correct answer- Using the data collected provides a collection of problems and
diagnosis-related groups (DRGs) that can help the care team determine discharge
needs. Review of demographic data can provide information after validation that
the information is correct during the assessment phase of contact with the patient
and family.
The electronic health record is a tool used by the coordination team and others to
gather information on what is going on with the patient, by providing information on
both the current situation and the medical history. It can also include advance directive
information for the future.
Where should the documentation of the care plan be recorded?
Correct answer- In the care planning module of the electronic health record
The electronic health record is where all the care team members have access to the
record of the patient, and it is the official health record for that patient.
A pregnant client is living in the wilds of Alaska. She is not considered to be high risk
and there is no reason for her to stay close to town since a frontier midwife is available
to travel to her home every month.
What would the care coordinator recommend for the client?
Correct answer- Satellite telecommunications device
A satellite phone is recommended to ensure that if any questions arise when the
midwife is not available, the client can call for help.
Which statement describes how a healthcare coordinator improves the quality of care
delivered in the community?
Correct answer- Serves as a bridge between patients, families, and other health care
providers.
Care coordinators organize care provided by multiple providers that may not have the
ability or means to communicate with each other. Coordinating care improves disease
management and patient compliance, offers resources, and removes barriers.
A care coordinator collaborates with health care providers to ensure that a patient with a
chronic health problem receives appropriate care, avoids hospitalization, and attends
follow-up visits as scheduled.
For which reason should the healthcare coordinator use health information technology
(HIT) to improve a patient's care?
, WGU D046 Intro to Care Coordination Final
Exam 2023 With Correct Answers as per the
Marking scheme
Correct answer- It improves communication between clinicians and inpatient and
outpatient healthcare settings.
HIT improves communication between multiple clinicians and clinical sites by improving
access to the patient's medical and medication history, plan of care, referral history, and
support services.
A care coordinator is scheduled to meet with adolescents and adult patients in a
community clinic.
Which action could a healthcare coordinator take to demonstrates how care
coordination improves in disease management?
Correct answer- Meet with the school nurse to review the action plans for students with
asthma.
Care coordination interventions for patients with chronic diseases effectively link
outreach, support services, education and guidance. Meeting with the school nurse to
review the action plans for students with asthma ensures compliance with medication
use and administration in a location convenient for the patient and care providers.
What are the outcome goals of the Ambulatory Integration of Medical and Social (AIMS)
model?
Correct answer- To obtain patient engagement, identify a best practice care model,
manage cases as a team, and identify the potential ongoing needs of the patient and
family to maintain optimal health
The AIMS model goals are patient engagement, care plan development, case
management, and ongoing care as needed.
What occurs during the patient engagement and assessment phases of the AIMS
model?
Correct answer- The patient engagement and assessment phases occur during the
initial introduction and detailed interview. This allows for the care coordinator and
patient to build a trusting relationship and identify the goals and outcomes for care
delivery, identify what part each team member will play in the ongoing care team, and
identify any concerns that need to be addressed to improve the potential for meetings
the goals of care delivery.
The introduction of the care coordinator to the care planning process, review of the aims
of the team to facilitate optimal health, and incorporation of whatever considerations
need to be addressed are vital to a quality outcome. The client and family should be
actively engaged in the process.
What is the goal for the case management phase in the AIMS model?
Correct answer- The goals are about managing the care plan and ensuring that the
goals of the plan are considered and modified as needed, and to offer support to the
team, the patient, and the family for the success of the care delivery.
The care management phase is to evaluate the goals, modify the plan as needed, and
to support the care team, patient, and family as needed to meet the goals of the AIMS
model.
