Care Coordination Jeopardy Template

General	Care coordination services	Care Coordination Policies	Outcomes	Care Coordination Processes
100 care coordination program description Document that includes program goals, structure, evidence, program processes for patient identification, intake and assessment and services.	100 service navigation navigating clients to social and community resources to facilitate meeting social and environmental unmet needs	100 orientation and on-going staff training Policy name that describes staff orientation and training opportunities for existing staff	100 Performance Management Program A program to ensure a systematic process for identifying, collecting and assessing data to measure the care coordination program's effectiveness	100 assessments various questions asked with patients/families to gather patient information
200 .population engagement A critical part of care coordination- can be done through relationship building, motivational interviewing and rewards/incentives	200 behavioral health services Service provided by staff with an LCSW or LCPC staff member	200 Home visit safety Always let the administrative assistant know when you are leaving and note in your calendar the patient you are visiting as a part of _____________	200 patient satisfaction survey Survey completed annually to obtain feedback from patients	200 PHQ-9 Tool that is used if patient screens positive on PHQ-2
300 evidence based guidelines nationally recognized practice guidelines	300 complex care management Targets high costs patients with cancer, HIV, etc.	300 rights and responsibility document document that helps ensure that all patients understand Blessing Hospital's commitment to assuring the rights of patients are honored and to assure that patients understand what is expected of them	300 Quality of life survey what patient survey measures physical and mental health	300 transition Movement of patient from one care setting to another, usually as the patients health status changes
400 patient centered medical home model a health care model in which individuals use primary care practices as the basis for accessible, continuous, comprehensive and integrated care	400 conditions managed through chronic condition management COPD, hypertension, lipids, CHF	400 intervals at which we communicate with providers upon intake, when something changes with a patient, when patient is not following treatment plan, not able to work with patient to meet goals, services are being discontinued, completion of care coordination	400 utilization outcome measures ED and inpatient measures	400 long term goals Goals that are generally resolved in one year
500 The BPS Practice Council and the Evidence Based Medicine Committee BPS provider led committees that help provide oversite to care coordination	500 Risk factors for the care transitions program two or more chronic conditions, poly-pharmacy, cognitive decline, limited social support, readmission within 30 days	500 topics that could potentially be discussed during a patient conference physical status of patient, diagnosis and treatments prescribed, patient problems and needs, patient progress towards goals, revisions to care plans, discharge plans	500 reduction in BMI outcome that has shown the least improvement over the years we have provided care coordination services	500 criteria that may generate a care coordination referral The following are __________: when patient is discharged from the hospital with risk for readmission, diagnoses related to chronic targeted conditions, social service needs, behavioral health services

Care Coordination

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