Community LT clients who are identified by the CM as stable.
Who are the SN target clients?
100
The method that CMs will use to connect with GPs in their local communities.
What is regularly scheduled teleconference calls?
100
CARE Management.
What is our clinical approach to care?
100
Characteristics of clients managed by the CM.
What are complexity and high care needs?
200
Uses this program to book clinicians visits.
What is the Outlook Calendar?
200
Approximately 250 clients.
What is the target caseload size for the SN?
200
Name at least one of the benefits of GP-CM teleconferences.
What is proactive care planning, sharing of client information, preventing crisis? (any one will do!)
200
The approach used to coach clients and jointly set health related goals.
What is Self Management Support?
200
The number of communities where the IHN has been implemented so far.
What is 7?
300
Can book this for up to 30 days per year.
What is a respite bed?
300
The SN uses this method or modality to connect with LT clients to provide proactive coaching and monitoring.
What is the telephone?
300
The FH HH Program medical Director
Who is Dr Grace Park?
300
Clients are most vulnerable at this point.
What are Care Transitions?
300
Client centered, anticipatory, proactive support and intervention.
What is CARE management?
400
Can initiate this type of Waiver.
What is an Eligibility Waiver for clients without BC Residency?
400
AT LEAST every 6 months.
What is how often the SN will connect with the LT clients to review goals of care.
400
Only these GPs will be connected with a CM.
Who are GPs with practices in the same community as their local HH office?
400
An approach to ensure Health Literacy.
What is teach back? (checking for understanding)
400
An accomplishment of or ability to accomplish a job with a minimum expenditure of time and effort.
What is an efficiency?
500
Can gather client information to complete this type of assessment.
What is the Financial Assessment?
500
May use these tools in surfacing client goals.
What is the bubble diagram and the Health Improvement Plan?
500
One of the goals of regular scheduled communication between the GP and the CM.
Any of the following:
What are improved client outcomes, preventing ER and acute care visits and improving provider experience. (Triple Aim)
500
The Model of Accountable Care is 1 core component of CARE Management. Name the 2 other core components of CARE Management.
What are Self Management Support and Care Transitions?
500
MoH objectives in response to the demands of the current health care system:
Improved population health
Improved patient/provider experience
Sustainability of Health Care system