Podcast
Questions and Answers
What is the primary goal of discharge planning?
What is the primary goal of discharge planning?
- To provide long-term care within the hospital premises
- To ensure a smooth transition of patients from a health organization to their next destination (correct)
- To keep patients in the hospital for as long as possible
- To reduce the number of patients admitted to hospitals
When should discharge planning with coordination of services ideally begin?
When should discharge planning with coordination of services ideally begin?
- Just before the patient is discharged
- During the patient's stay at the hospital
- After a patient has already left the hospital
- At the time of patient admission to the hospital (correct)
Which of the following disorders would NOT typically be treated in a psychiatric hospital?
Which of the following disorders would NOT typically be treated in a psychiatric hospital?
- Schizophrenia
- Bipolar disorder
- Dissociative identity disorder
- Cancer (correct)
In discharge planning, what is the purpose of determining the appropriate post-hospital destination for a patient?
In discharge planning, what is the purpose of determining the appropriate post-hospital destination for a patient?
What does a transition coach typically help patients with in the context of discharge planning?
What does a transition coach typically help patients with in the context of discharge planning?
Which term describes a small hospital specifically trained and staffed to provide healthcare services in remote and rural areas?
Which term describes a small hospital specifically trained and staffed to provide healthcare services in remote and rural areas?
What is the main role of the transitional care nurse/advanced practice nurse/gerontological nurse in the model described?
What is the main role of the transitional care nurse/advanced practice nurse/gerontological nurse in the model described?
What is the focus of the High-intensity Care Team in the GRACE Team Care Model?
What is the focus of the High-intensity Care Team in the GRACE Team Care Model?
Which of the following is a key component of patient participation in the model discussed?
Which of the following is a key component of patient participation in the model discussed?
What is the objective of restorative care as mentioned in the text?
What is the objective of restorative care as mentioned in the text?
Which professionals head the High-intensity Care Team described in the text?
Which professionals head the High-intensity Care Team described in the text?
What is the focus of postdischarge follow-up as part of the model discussed?
What is the focus of postdischarge follow-up as part of the model discussed?
What factors does a case manager or social worker usually consider when selecting a setting for a patient?
What factors does a case manager or social worker usually consider when selecting a setting for a patient?
Who usually identifies a patient's needs for a smooth and safe transition from the acute care hospital to their discharge destination?
Who usually identifies a patient's needs for a smooth and safe transition from the acute care hospital to their discharge destination?
Which model emphasizes the role of a transition coach in facilitating the discharge of a patient to home or a rehabilitation center?
Which model emphasizes the role of a transition coach in facilitating the discharge of a patient to home or a rehabilitation center?
What are the four pillars on which Coleman’s “Care Transitions Program” (2006) is based?
What are the four pillars on which Coleman’s “Care Transitions Program” (2006) is based?
Which model emphasizes comprehensive discharge planning and follow-up for older adults who are chronically ill?
Which model emphasizes comprehensive discharge planning and follow-up for older adults who are chronically ill?
What does Naylor’s “Transitional Care Model” (2009) emphasize for older adults who are chronically ill?
What does Naylor’s “Transitional Care Model” (2009) emphasize for older adults who are chronically ill?
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Study Notes
Models of Care
- The transitional care model consists of six key components: in-hospital assessment, discharge preparation, patient participation, continuity of care, predischarge assessment, and postdischarge follow-up.
- The High-Intensity Care Team (GRACE Team Care Model) is led by a nurse practitioner and a social worker, supporting primary care physicians and addressing patients' health conditions.
Restorative Care
- Restorative care aims to help individuals regain maximal functional status and enhance quality of life through promotion of independence and self-care.
- Patients often require restorative care after early discharge from hospitals.
Types of Hospitals
- Mental health facilities, also known as psychiatric hospitals, specialize in treating severe mental disorders.
- Rural hospitals are small hospitals trained and staffed to provide healthcare services in remote and rural areas.
Discharge Planning
- Discharge planning is a coordinated, interprofessional process that develops a plan for continuing care after a patient leaves a healthcare agency.
- Discharge planning involves determining the appropriate post-hospital destination, identifying a patient's needs, and meeting those needs while the patient is still hospitalized.
- Discharge planning models include Coleman's "Care Transitions Program" and Naylor's "Transitional Care Model".
Discharge Planning Models
- Coleman's "Care Transitions Program" (2006) emphasizes the role of a transition coach and is based on four pillars: medication self-management, patient-centered record, follow-up, and indicators of worsening medical condition.
- Naylor's "Transitional Care Model" (2009) focuses on comprehensive discharge planning and follow-up for older adults who are chronically ill.
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