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When does care coordination begin and end - ✔✔Prior to admission for elective
procedure - 30-90 days after discharge.
Pay for performance models have a greater emphasis on - ✔✔Value based
purchasing, readmission, Hospital acquired conditions
What factors effect value based purchasing? - ✔✔quality of care,, reduce
adverse events/safety, improving patient experience, efficiency/delivering low
cost care.
What does the Acronym LACE stand for in the Lace Assesment tool.. -
✔✔LENGTH of Stay, ACUITY of Admission, COMORBIDITY, EMERGENCY
Department Visits.
What are the 8 ps in The Society for Hospital Medicines Project Boost Risk
Assesment - Readmission Assement - ✔✔Problems with Medications,
Psychological,
Principal Diagnosis,
Physical Limitations,
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,Poor Health Literacy,
Patient Support,
Prior Hospitalization,
Palliative Care
Components of RED ( Reengineered discharge) - ✔✔Asses need for translator,
sched f/u appointments,
f/u on outstanding test results,
coordinate post d/c out-patient services,
obtaining medications
national d/c guidelines,
d/c teaching,
educate on what to do if problems arise,
assess pt understanding,
d/c summary to outside providers, d/c follow up call.
After Hospital Care Plan (AHCP)
In regards to Value Based Pricing/payments, What factors weigh heavily in
clinical care outcomes? - ✔✔mortality
In regards to Value Based Pricing/payments, what factors are considered in
Patient experience of Care - ✔✔staff communication,
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,receiving written d/c information, warning signs,
explanation of medications,
pain management,
overall experience.
In regards to Value Based Pricing/payments, what factors are used to determine
payout based on efficiency. - ✔✔spending per beneficiary, 3 days prior to
admission to 30 days post d/c.
Resource utilization,
length of stay,
post acute services.
In regards to Value Based Pricing/payments, what factors are used to determine
payout for safety? - ✔✔Various patient safety factors and infection rates
What is the definition of health literacy ? - ✔✔the degree to which individuals
have the capacity to obtain, process and understand basic health information
and services needed to make appropriate health decisions.
What are social determinants of health? - ✔✔Conditions on which people born,
grow, live, work and age. these can either promote or hinder a clients health
status. Ie employment, social inclusion/exclusion, education, neighborhood, etc.
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, What are the components of a psychosocial history - ✔✔family composition,
education, occupation, psychological and/or psychiatric functioning, living
siuation, support system, transportation concerns, life changes or stressor,
cooing skills, social/ community involvement, spiritual aspects and concerns,
self care, cognitive or perception problems, financial concerns.
What is the required assessment for admission to a nursing home for a patient
with a diagnosis of mental retardation or mental illness to assure appropriate
placement - ✔✔Federal Pre-Admission Screening and Resident Review. Some
states may require additional screening tools.
What factors effect social determinents of health? - ✔✔economic stability,
neighborhood and built environment, education, food, community and social
context, health and health care.
Required assessment for admission to a nursing home for a patient with a
diagnosis of mental retardation - ✔✔Federal Pre-Admission Screening and
Resident Review. Some states may require additional screen in ng tools.
What is utilization and review? - ✔✔reviewing patients clinical condition and
providing decis I on support to MD on bed and billing status. ie observation, Out
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