Care Coordination and Transitions of Care
The Care Coordination and Transitions of Care domain tests handoffs, medication reconciliation, discharge planning, and interprofessional communication. The exam wants you to prevent information loss and avoidable readmissions.
Core rules and concepts
- Every transition needs a structured handoff. SBAR (Situation, Background, Assessment, Recommendation) and I-PASS are common. Include allergies, code status, isolation, pending results, and what the receiving nurse must do next.
- Medication reconciliation occurs at admission, transfer, and discharge, not only at discharge. Compare the home list, hospital orders, and discharge prescriptions; flag duplicates and omissions.
- Discharge planning begins on admission. Assess caregiver availability, transportation, home safety, finances, health literacy, and access to medications and equipment.
- Use teach-back, written instructions in plain language, and a confirmed follow-up appointment. A warm handoff to the next setting is stronger than a faxed summary alone.
- Case managers and social workers address resources and coverage; pharmacists address medication issues; the nurse coordinates and advocates.
Worked example
A patient with heart failure is going home. The nurse reconciles medications, confirms the patient can obtain the prescriptions, teaches daily weights and a symptom action plan, uses teach-back for low-sodium choices, and verifies a follow-up visit within seven days. She confirms the patient has a working scale and transportation. Reasoning: each gap, such as duplicate diuretics or no scale, is a predictable readmission risk.
Traps that cost marks
- Providing verbal-only discharge instructions at the last minute.
- Doing medication reconciliation only at discharge.
- Omitting pending laboratory results or tests from the handoff.
- Assuming a family member will manage without assessing their ability and willingness.