Ambulatory Care Nursing: Comprehensive Exam Preparation, Exams of Nursing

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COMPLETE QUESTIONS AND ANSWERS

FOR AMBULATORY CARE EXAM 1

Elements of CCTM - CORRECT ANSWER--Assuming accountability

• Providing patient support
• Building relationships and agreements among providers that lead to shared expectations for communication and care
• Developing connectivity via electronic or other information pathways that encourage timely and effective information flow between Care coordination - CORRECT ANSWER-Need high quality referral or transition Should be timely Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors. Effective: referrals and transitions are based on scientific knowledge Patient centered efficient Equitable 6 principles of CCTM Nusing - CORRECT ANSWER-These six principles provide a basis for establishing an informed and collaborative care coordination process that includes all staff, key stakeholders, and nurse leaders across the continuum of care:
• Know how care is coordinated in your setting
• Know who is providing care
• Establish relationships with multiple entities and individuals who can work together to improve care coordination and transition management systems
• Know the value of technology, its impact on workflow, and the roles of care coordination team members
• Engage the patient and family
• Engage all team members in care coordination The logic model and CCTM - CORRECT ANSWER-The Logic Model depicts program outcomes, how the program is supposed to accomplish these outcomes and what is the basis (logic) for these expectations.

Links program inputs (resources) and activities to the program products and outcomes while communicating the logic Components: Inputs: resources that go into the program Activities: actual events or actions that take place Products: direct tangible output of program activities Outcomes: impact of the program; the sequence of effects triggered by the program, often expressed in terms of short term, intermediate, and distal outcomes Stages of change model - CORRECT ANSWER-Stages: ◦Precontemplation - no intention to change in the next 6 months ◦Contemplation - intend to change in the next 6 months ◦Preparation - intend to take action in the immediate future ◦Action - observable changes ◦Maintenance - have made changes and working to prevent relapse ◦Termination - not always recognized as a stage Public health nursing - CORRECT ANSWER-Lillian Wald visiting nurses - decision that need public health nurses and integrate courses or have it be post grad

• Education is important Community - pathological social conditions Treat community and other sources Industrialization/depression
• Lack of coordination, resources, access Challenges - communicable disease, stresses of immigration and SES disparity Cost of healthcare unsustainable Fiscal caps pushed large volumes of services to outpatient Acuity of patient care escalated in ambulatory areas Affordable Care Act - CORRECT ANSWER-In 2011, the law provided for free preventive care for seniors such as annual wellness visits and personalized prevention plans Community Care Transitions program for at risk Senior Adults, preventing ED visits and hospital readmissions increased reimbursement for primary care State sanctioned Patient Centered Medical Homes Physician reimbursement changing from Fee-for-Service to Value Based Care models Misconceptions of ambulatory care nursing - CORRECT ANSWER--a misconception that the acute care setting is the point of access for individuals requiring care

coordination and transition management, when in fact the ambulatory care setting is the point of access;

• a misconception that care transitions originate with a hospitalization rather than recognizing the multiple care transitions occurring among diverse ambulatory care settings;
• a misconception that a measure of care coordination and transition management is handing patients written instructions prior to discharge, a single intervention of a hand- off but not a measure of performance of care being coordinated or the transition being managed;
• a misconception that care coordination and transition management are discrete points of communication rather than a continuous conversation with ongoing communication;
• a misconception that individuals with complex health care needs are equipped with self-management skills and decision-making skills to know what to do when their condition worsens or they develop a complication
• a misconception that individuals with complex health care needs seek care in traditional primary care settings, when diverse ambulatory settings are serving vulnerable populations including uninsured, Medicaid, and geographically and economically disadvantaged. 3 General contexts of ambulatory care nurses: - CORRECT ANSWER-- episodic/preventative care
• chronic disease management
• practice operations Episodic/preventative care - CORRECT ANSWER--Teletriage
• Medication recon
• Promote adherence to treatment
• HPI/patient health status - flag key findings for prioritization Chronic disease management - CORRECT ANSWER--Telecommunication
• Discharge strategies - better education
• Early identification of sx Practice Operations - CORRECT ANSWER--Guide teletriage
• QI Data analysis practice leadership
• Prioritizing patient appointment access and service coordination RN skills were viewed as vital to manage patient flow and capacity, enhance same day care needs, and accommodate after hours scheduling
• Trained and supervised LPNs and MAs
• Directed community based teams
• Managed patient navigation centers
• Providing continuity when PCPs were unavailable Position statement for ambulatory nurses - CORRECT ANSWER-•RNs enhance patient safety and the quality and effectiveness of care delivery and are thus essential and irreplaceable in the provision of patient care services in the ambulatory setting.

•RNs are responsible for the design, administration, and evaluation of professional nursing services within an organization in accordance with the framework established by state nurse practice acts, nursing scope of practice, and organizational standards of care.

• RNs provide the leadership necessary for collaboration and coordination of services, which includes defining the appropriate skill mix and delegation of tasks among licensed and unlicensed health care workers. •RNs are fully accountable in all ambulatory care settings for all nursing services and associated patient outcomes provided under their direction. Key elements of ambulatory care nursing: - CORRECT ANSWER- Clients who are helped most by care coordination: - CORRECT ANSWER--Chronically ill patients
• Someone who doesnt have effective PCP - many ED visits Who is failed by primary care? The question is posed this way because we can view most hospitalizations as failures of preventive primary care. A blunt assessment can be a simple scan of the most frequent users of hospital-based services — that is, individuals who visit the emergency room frequently and whose illnesses often warrant inpatient care. Frequent use is defined differently in different hospital settings; some hospitals simply focus on those who made three or more emergency room visits in the past year, while others define "frequent" as five or more emergency department visits in the past year, and still others review billed and recouped charges to identify the 10 or 20 most expensive patients. Sophisticated predictive modeling can further identify individuals who are likely to drive high future health care costs, as distinct from those whose illnesses require acute care for a given episode. An assessment of ambulatory-sensitive admissions is another way to identify those who could benefit from better coordinated care and can indicate inadequate access to primary care. See the Commonwealth Care Alliance method on page 9 as an example of effective identification and stratification of patients. Assuming accountability - CORRECT ANSWER-Referrals are more likely to be successful if referring providers and consultants understand each other's expectations and preferences, and referring practices have the staff and information infrastructure to help patients and their information get where they need to go Patients and their families can help ensure effective and efficient referrals if they are adequately informed and supported to play an active role. PCMHs must try to work with area hospitals and ERs to increase the likelihood that they will receive timely, useful information when their patients are admitted and discharged. An important component of assuming accountability is having the ability to track referrals and transitions to assure their successful completion.

Providing patient support - CORRECT ANSWER-Referral coordinator should help by identifying any logistical or financial barriers Helps gets timely appointments Assures the transfer of clinical information Tracks progress and assists patients encountering difficulties Key elements of chronic care model - CORRECT ANSWER-1. Health System: Create a culture, organization and mechanisms that promote safe, high quality care.

2. Delivery System Design: Assure the delivery of effective, efficient clinical care and self-management support
3. Decision Support: Promote clinical care that is consistent with scientific evidence and patient preferences
4. Clinical Information Systems: Organize patient and population data to facilitate efficient and effective care
5. Self-Management Support: Empower and prepare patients to manage their health and health care
6. The Community: Mobilize community resources to meet needs of patients

• Community informs/activates the patient
• Health systems is delivery - situational support, promote prepared proactive practice team
• Activated patient has good interaction with the team and that leads to improved outcomes Understand the models that shape a provider's personal attitudes toward substance misuse. Recognize the impact of those underlying models as they apply to clinical practice. - CORRECT ANSWER-Moral model: Attribute addiction to personal weakness, lack of character or willpower, or an outright disregard for social norms Use of substances is often considered volitional, solely a matter of personal choice Behavioral model: Addictions are habits that have been overlearned through observation, interactions with the environment Behaviors can be examined, challenged, and changed 12 step model: Spiritual program of action Individual should seek his or her own conception of power greater than self Disease model: Disease of brain - outside voluntary control Prevailing medical model- based on medical model Bio-psycho-social-spiritual model:

Most reflective of holistic perspective of nursing 12 step and disease models Intertwined with spiritual Apply principles of care coordination to specific client challenges. How would a care coordinator be able to help a particular complex client? - CORRECT ANSWER-Primary and acute communicating

• More comprehensive EMR system to promote continuity of care
• Referral to specialists and simplifying issues
• Ensuring resources are available first
• Transportation, telephone, healthy food, home,
• Simplify complexity of system Transition coaches Bridge care after hospital discharge Care coordinator Promote self management, patient advocacy Correct assignment based on skillset Reimbursement from Medicare ***Know the elements of the NIH Clear and Simple Communications process and be able to apply them to a clinical example. - CORRECT ANSWER-5 Steps for Clear and Simple communication:

1. Determine/define target audience, assess learning style
2. Target audience research, assess rumors/myths and misinfo, determine feelings, fill in gaps in info
3. Develop concept for product, use info from audience research to outline objectives/style/format/approach, putting it together
4. Develop content, visual defined features, tailored to needs of audience to literacy
5. Pre-test or revise draft materials, measure response of audience to product, measure their comprehension Below Basic - CORRECT ANSWER--No more than the most simple and concrete literacy skills locating easily identifiable information in short, commonplace prose texts

• locating easily identifiable information and following written instructions in simple documents (e.g., charts or forms)
  • locating numbers and using them to perform simple quantitative operations (primarily addition) when the mathematical information is very concrete and familiar locating easily identifiable information in short, commonplace prose texts ■ locating easily identifiable information and following written instructions in simple documents (e.g., charts or forms) ■ locating numbers and using them to perform simple quantitative operations

(primarily addition) when the mathematical information is very concrete and familiar Circle the date Short instructions Clearly written pamphlet Primary addition - 1+1= Identify how often a person should have a specified medical test, based on information in a clearly written pamphlet. Intermediate - CORRECT ANSWER--Majority of adults had intermediate health literacy

• reading and understanding moderately dense, less commonplace prose texts as well as summarizing, making simple inferences, determining cause and effect, and --- recognizing the author's purpose
• locating information in dense, complex documents and making simple inferences about the information
• locating less familiar quantitative information and using it to solve problems when the arithmetic operation is not specified or easily inferred ■ reading and understanding moderately dense, less commonplace prose texts as well as summarizing, making simple inferences, determining cause and effect, and recognizing the author's purpose ■ locating information in dense, complex documents and making simple inferences about the information ■ locating less familiar quantitative information and using it to solve problems when the arithmetic operation is not specified or easily inferred
• OTC med interactions
• Read a prescription label
• Chart determined BMI
• Age range vaccinations Proficient - CORRECT ANSWER--reading lengthy, complex, abstract prose texts as well as synthesizing information and making complex inferences
• integrating, synthesizing, and analyzing multiple pieces of information located in complex documents
• locating more abstract quantitative information and using it to solve multi- step problems when the arithmetic operations are not easily inferred and the problems are more complex reading lengthy, complex, abstract prose texts as well as synthesizing information and making complex inferences ■ integrating, synthesizing, and analyzing multiple pieces of information located in complex documents ■ locating more abstract quantitative information and using it to solve multistep problems when the arithmetic operations are not easily inferred and the

problems are more complex

• Calculate health care costs via table with variation
• Define medical term from a complex doc
• Legal document applicable to health care situations Apply appropriate educational approaches and tools for each level of literacy: basic, intermediate, proficient. - CORRECT ANSWER-Below Basic: Demonstration, verbal, Simple instructions Intermediate: Prose literacy etc - CORRECT ANSWER-The knowledge and skills needed to perform prose tasks (i.e., to search, comprehend, and use information from continuous texts). Prose examples include editorials, news stories, brochures, and instructional materials. Prose texts can be further broken down as expository, narrative, procedural, or persuasive Document literacy. The knowledge and skills needed to perform document tasks (i.e., to search, comprehend, and use information from noncontinuous texts in various formats). Document examples include job applications, payroll forms, transportation schedules, maps, tables, and drug and food labels. ■ Quantitative literacy. The knowledge and skills required to perform quantitative tasks (i.e., to identify and perform computations, either alone or sequentially, using numbers embedded in printed materials). Examples include balancing a checkbook, figuring out a tip, completing an order form, and determining the amount of interest on a loan from an advertisement. Basic - CORRECT ANSWER-reading and understanding information in short, commonplace prose texts ■ reading and understanding information in simple documents ■ locating easily identifiable quantitative information and using it to solve simple, one-step problems when the arithmetic operation is specified or easily inferred indicates skills necessary to perform simple and everyday literacy activities

Explain why it is difficult for people to know if they have a specific chronic medical condition, based on information in a one-page article about the medical condition. Give two reasons a person with no symptoms of a specific disease should be tested for the disease, based on information in a clearly written pamphlet. Motivational Interviewing Acronym - CORRECT ANSWER-R- resist the righting reflex -- dont tell them theyre wrong - shut down U - Understand pt's own motivations, L - Listen with empathy E - Empower the patient O - open ended questions A - affirming R - reflective listening S - summarizing Motivational interviewing principles - CORRECT ANSWER-1. Asking permission: Communicates respect for clients. Also, clients are more likely to discuss changing when asked, than when being lectured or being told to change.

2. Eliciting/evoking change talk --What would you like to see different about your current situation?"

• How can I help you get past some of the difficulties you are experiencing?"
• "• "Suppose you don't change, what is the WORST thing that might happen?" "If you make changes, how would your life be different from what it is today?"

3. Exploring importance and confidence
4. Open ended questions
5. Reflective listening -
6. Normalizing - many people feel this way
7. Decisional balancing - To realize that (a) they get some benefits from their risky/problem behavior, and (b) there will be some costs if they decide to change their behavior. pros/cons
8. Columbo Approach: deploying discrepancies "On the one hand you're coughing and are out breath, and on the other hand you are saying cigarettes are not causing you any problems. What do you think is causing your breathing difficulties?"
9. Statements supporting self efficacy - affirmation
10. Readiness to change ruler
11. Advice/feedback - facts about outcomes "So you said you are concerned about gaining weight if you stop smoking. How much do you think the average person gains in the first year after quitting?"

12. Summary/mirroring
13. Therapeutic paradox - Paradoxical statements are used with clients in an effort to get them to argue for the importance of changing. "Bill, I know you have been coming to treatment for two months, but you are still drinking heavily, maybe now is not the right time to change?") Precontemplation- not ready - CORRECT ANSWER-People in the Precontemplation stage do not intend to take action in the foreseeable future, usually measured as the next six months. Being uninformed or under informed about the consequences of one's behavior may cause a person to be in the Precontemplation stage. Multiple unsuccessful attempts at change can lead to demoralization about the ability to change. Both the uninformed and under informed tend to avoid reading, talking, or thinking about their high-risk behaviors. They are often characterized in other theories as resistant, unmotivated, or unready for help. The fact is, traditional programs were not ready for such individuals and were not designed to meet their needs. No intention for action within 6 mos Contemplation - getting ready - CORRECT ANSWER-Contemplation is the stage in which people intend to change in the next six months. They are more aware of the pros of changing, but are also acutely aware of the cons. In a meta-analysis across 48 health risk behaviors, the pros and cons of changing were equal (Hall & Rossi, 2008). This weighting between the costs and benefits of changing can produce profound ambivalence that can cause people to remain in this stage for long periods of time. This phenomenon is often characterized as chronic contemplation or behavioral procrastination. Individuals in the Contemplation stage are not ready for traditional action-oriented programs that expect participants to act immediately. Intend to change in next 6 mos, aware of issue Preparation - ready - CORRECT ANSWER-Preparation is the stage in which people intend to take action in the immediate future, usually measured as the next month. Typically, they have already taken some significant action in the past year. These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book, or relying on a self-change approach. These are the people who should be recruited for action-oriented programs. Make changes in next month Action - CORRECT ANSWER-Action is the stage in which people have made specific overt modifications in their lifestyles within the past six months. Because action is observable, the overall process of behavior change often has been equated with action. But in the TTM, Action is only one of six stages. Typically, not all modifications of

behavior count as Action in this Model. In most applications, people have to attain a criterion that scientists and professionals agree is sufficient to reduce risk of disease. For example, reduction in the number of cigarettes or switching to low-tar and low- nicotine cigarettes were formerly considered acceptable actions. Now the consensus is clear—only total abstinence counts. Specific modifications in past 6 mos actively engaged Maintenance - CORRECT ANSWER-Maintenance is the stage in which people have made specific overt modifications in their lifestyles and are working to prevent relapse; however, they do not apply change processes as frequently as do people in Action. While in the Maintenance stage, people are less tempted to relapse and grow increasingly more confident that they can continue their changes. Based on self-efficacy data, researchers have estimated that Maintenance lasts from six months to about five years. While this estimate may seem somewhat pessimistic, longitudinal data in the 1990 Surgeon General's report support this temporal estimate. After 12 months of continuous abstinence, 43% of individuals returned to regular smoking. It was not until 5 years of continuous abstinence that the risk for relapse dropped to 7% (USDHHS). Dont make changes as frequently as people in action Termination - CORRECT ANSWER-Termination is the stage in which individuals are not tempted; they have 100% self-efficacy. Whether depressed, anxious, bored, lonely, angry, or stressed, individuals in this stage are sure they will not return to unhealthy habits as a way of coping. It is as if their new behavior has become an automatic habit. Examples include adults who have developed automatic seatbelt use or who automatically take their antihypertensive medication at the same time and place each day. In a study of former smokers and alcoholics, researchers found that less than 20% of each group had reached the criteria of zero temptation and total self-efficacy (Snow, Prochaska & Rossi, (1992). The criterion of 100% self-efficacy may be too strict or it may be that this stage is an ideal goal for population health efforts. In other areas, like exercise, consistent condom use, and weight control, the realistic goal may be a lifetime of maintenance. Recall and apply the principles of mental health screening to the ambulatory care setting. Use the ppt and Strobe article (with highlights) for principles and application. - CORRECT ANSWER--Screening for potential problems: who do you screen?

• Consider risk factors for suicide: substance abuse, loss of spouse or significant other, mental health issues, possibly depression
• Consider risk factors for depression: life-altering change, older age, mental health issues, environmental circumstances Recognition of warning signs

Strobe article: Know the provider issues of lack of awareness, resource, and skills in addressing substance misuse. - CORRECT ANSWER-Awareness: Everyone has biases and prejudices, both conscious and unconscious. It is important as a provider to try to recognize the unconscious biases as much as possible so that they won't have an effect on the way clients are treated. Some unconscious biases have to do with someone's beliefs about the root causes of addiction and the best way to address it. Internal awareness: provider's personal attitudes/beliefs/bias External awareness: recognition of warning signs, the need for screening Resource: Limited time: pressure to see greater numbers of clients Payor impact: reimbursement for time spent Need for referral or information resources Skills: Assessment: screening tools, labs, conversation Diagnosis: substance use disorder (as opposed to addiction/dependence). Includes severity of the disorder. Plan: use of behavior change theories (Motivational Interviewing, Stages of Change). Based on the assessment of severity: minimal use, non-problematic, at-risk or heavy, repetitive and intense. Implementation: may include collaboration Evaluation: ongoing Apply the nursing process to a clinical example of substance misuse in the outpatient setting.. - CORRECT ANSWER-Assessment - subjective objective data, labs, conversation, Dx - based on DSM 5, substance use disorder, NPs can dx Organization/plan - based on behavioral change theory - like how ready they are to change, resources, Severity Implementation - interdisciplinary, Evaluation - ongoing Strobe - evaluation and having patience, Nurse client relationship for substance abuse - CORRECT ANSWER--Recognize own beliefs to avoid counter transference

• Normalizing
• avoid judgment
• Affirmations

AUDIT - CORRECT ANSWER-The Alcohol Use Disorders Identification Test (AUDIT) is an instrument adapted from the World Health Organization. Validation studies have been carried out in the United States and other countries. The drinking limits have been adjusted to fit the US guidelines for average drinking. The first three questions are quantity and frequency questions. The next three questions (4-6) ask about possible alcohol dependence. These questions are important because possibly dependent patients receive a more intensive intervention. The final four questions (7-10) ask about a series of alcohol-related problems that patients may have experienced. DAST - CORRECT ANSWER-The Drug Use Questionnaire or DAST-10 is a medical screening tool/aide to help you document the patient's drug abuse (prescribed, over-the- counter, non-medicinal) history over the past 12 months, excluding alcohol and tobacco. The summative score assigned at the end of the questionnaire will assist you in determining the patient's At-Risk score/zone. Alcohol and Drug Intervention Card - CORRECT ANSWER-The SECSAT Alcohol & Drug Intervention Card was developed to use as a guide and outline for a brief alcohol intervention with patients. One side includes a standard drink chart, low-risk alcohol consumption chart and a diagram to use as a visual aid to demonstrate level of risk based on the patient's AUDIT score. The other side includes an outline of an MI- based brief alcohol intervention, as well as including a menu of options for patients at higher levels of risk who may need additional forms of treatment. SBIRT - CORRECT ANSWER-An approach to the delivery of early intervention and treatment to people with substance use disorders and those at risk of developing these disorders. Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care. Elements of IHI care - CORRECT ANSWER-Individual and family assets Resources, gifts, and strengths Patient identification Care coordinator Care provider responsible for identifying an individual's health goals and coordinating services and providers to meet those goals Will have expertise in self management and patient advocacy