2 Care Coordination and Continuity Free Online FlashCards

What is care coordination?

Care coordination is the deliberate organization of care activities and information-sharing among the people involved in a person’s care.

What is a transition of care?

A transition occurs when a person moves between care settings, providers, or levels of care.

What should the care team do when preparing for a transition?

Prepare by identifying the person’s goals, care needs, preferences, risks, and likely support needs.

What is medication reconciliation?

Medication reconciliation compares medication lists and resolves differences; it is an important part of many transitions.

What is a shared care plan?

A shared care plan is a current, person-centered reference that coordinates actions across providers and settings and clarifies what each participant is doing.

What does continuity of services mean?

Continuity of services means arranging for needed care and supports to continue through a change in setting or provider.

What is the purpose of care coordination?

It helps ensure that a person’s needs and preferences guide safe, appropriate services, especially across providers or settings.

How should a care team clarify responsibility for tasks?

Identify who is responsible for each task and who will follow up, so responsibilities are clear across the care team.

Who should participate in care decisions and planning?

Include the person receiving care in decisions and planning; include their caregiver or support person with the person’s agreement.

Why is a safe transition more than a discharge?

A safe transition is a process, not simply a discharge; it requires a clear plan and communication between sending and receiving providers.

What makes a transition handoff effective?

Send accurate, relevant information to the receiving provider in time for them to act, clarify responsibility during the transfer, and confirm acceptance of the handoff.

What should transition support ensure the person or caregiver understands?

Explain the plan in understandable terms and check that the person or caregiver knows how to manage care and whom to contact with questions or worsening symptoms.