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Transitional Care

AJN, American Journal of Nursing: September 2008 - Volume 108 - Issue 9 - p 63
doi: 10.1097/01.NAJ.0000336421.34946.73
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LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to

  • explain problems that occur in transitioning patients between levels of health care and across care settings and list two models that may improve this care.

1. What factor has been linked to adverse events, low satisfaction with care, and high rehospitalization rates?

a. high nurse-to-patient staffing ratios on medical–surgical floors

b. holding admitted patients in the emergency department for more than 24 hours

c. limited time during office visits for older patients to ask questions about their medical care

d. poor "handoff" of older adults and their family caregivers from hospital to home

2. Which of these factors contributes to gaps in care during critical transitions?

a. the expense of prescribed medications

b. older adults' lack of motivation

c. limited access to essential services

d. family members' unavailability for providing care

3. According to the study by Levine et al (2006), how do family caregivers consistently rate their level of engagement in making discharge plans and the quality of their preparation for the next stage of care?

a. poor

b. fair

c. good

d. excellent

4. What was the result of the Collaborative Assessment and Rehabilitation for Elders program that provided access to a range of health, palliative, and rehabilitation services?

a. a 20% rehospitalization rate within 3 months of completing the program

b. a decrease in medication errors while enrolled in the program

c. improved function and decreased hospital use

d. minimal improvement in cognitively impaired older adults

5. According to a study by Foust and colleagues, which of these is a common problem during transition periods?

a. exacerbation of health problems

b. medication errors

c. lack of follow-up

d. missed appointments for mental health counseling

6. What was one of the components of the professional–patient partnership model used in Baltimore?

a. an advanced practice nurse provided traditional visiting nurse services

b. a questionnaire was used to assess the needs of patients and family caregivers at hospital discharge

c. an advanced practice nurse served as a "transitions coach"

d. a social worker visited patients at home twice a week for 4 weeks

7. According to studies, which of these is key to improving care transition and enhancing the support of family caregivers?

a. information systems, such as electronic medical records

b. adult day care programs to help relieve caregivers' burden

c. counseling sessions with social workers for family caregivers

d. Web camera devices for providing remote health care services


© 2008 Lippincott Williams & Wilkins, Inc.