3 Care Coordination and Continuity Free Online FlashCards

What is care coordination?

Care coordination deliberately organizes care activities among the patient and the people involved in their care to connect services, share information, and prevent gaps.

What should guide a coordinated care plan?

The patient’s goals and preferences should guide the care plan and help shape decisions about services and follow-up.

How should a care team assign tasks and oversight?

Assign actions to people whose roles and competence fit the task, and clarify who oversees the work and makes decisions.

What does SBAR stand for?

SBAR means Situation, Background, Assessment, Recommendation. It structures a message when raising a concern or requesting a decision.

What does a handoff transfer?

A handoff transfers both information and responsibility for care from one clinician to another.

When is the sending clinician accountable for a handoff?

The sending clinician remains accountable for a clear transfer until the receiving clinician understands the information and accepts responsibility.

Which patient and treatment details belong in a handoff?

Include the patient’s current condition, relevant history, allergies, risks, treatments, medication changes, and what needs monitoring.

How should a handoff handle pending test results?

Identify pending tests or results and specify who will review them and communicate the findings.

How can a team confirm a critical handoff instruction?

Use a confirmation step, such as read-back of a critical instruction or explicit acceptance of responsibility, to reduce ambiguity.

What should be documented after a handoff?

Document what was communicated, to whom, and any outstanding actions, following workplace policy.

What makes a referral more than giving a patient contact details?

Explain the referral’s purpose, check that it fits the patient’s needs and preferences, and send relevant information with the patient’s involvement. Follow privacy requirements and the patient’s choices.

What follow-up is needed after sending a referral?

Confirm that the receiving service got the referral and clarify who will act if an appointment is delayed or the service cannot accept the patient.