The Chronic Care Model

Every question here, with the answer

1. At the end of a morning visit, a nurse is preparing the self-management section of a care plan for a patient with hypertension. Which planned action best applies the Chronic Care Model's approach to helping the patient limit sodium intake?

   1. Work with the patient to agree on a sodium-reduction goal and identify strategies for achieving it.
   2. Select a sodium-reduction goal for the patient and explain the instructions for meeting it.
   3. Provide sodium-reduction education and ask the patient to develop a goal and strategies independently.
   4. Agree with the patient on a sodium-reduction goal and leave strategy development for the next visit.

   Answer: Work with the patient to agree on a sodium-reduction goal and identify strategies for achieving it.

   The model supports collaborative goal development and staff-assisted problem solving to help patients manage chronic disease. The other approaches provide education or establish a goal, but leave out either shared goal setting or current assistance with strategies for achieving it.

2. At 3:00 p.m., a nurse is updating the electronic care plan for a patient with a chronic illness who will continue care with another provider. Which planned actions directly use information sharing to support a smooth transition? Select all that apply.

   1. Retrieve best-practice guidelines for the patient's chronic condition from a clinical database.
   2. Make the patient's care-plan information available to the patient as part of coordinating ongoing care.
   3. Generate a list of patients with the same chronic disease to monitor their health status over time.
   4. Share the patient's current care-plan information with the provider who will continue care.
   5. Review the care team's performance and patient outcomes for the previous month.

   Answer: Make the patient's care-plan information available to the patient as part of coordinating ongoing care., Share the patient's current care-plan information with the provider who will continue care.

   Sharing patient-specific information with both the patient and the continuing provider supports coordination and smooth transitions. Performance monitoring and disease-specific patient lists serve other clinical information system functions, while retrieving guidelines provides decision support; none of these actions alone shares the patient's care information for this transition.

3. At 2:00 p.m., a clinic nurse is drafting a care plan for a patient with a chronic condition the nurse rarely encounters. The nurse is unsure which management approach is supported by evidence. Which action best addresses that uncertainty before completing the plan?

   1. Review the patient's recorded health-status trends to summarize progress over time.
   2. Access condition-specific best-practice guidelines through a clinical system or database.
   3. Review the patient's self-management goals to identify personal priorities.
   4. Review the care team's assigned roles and the patient's scheduled follow-up contacts.

   Answer: Access condition-specific best-practice guidelines through a clinical system or database.

   Decision support makes evidence-based guidelines available when clinicians are unfamiliar with a condition or unsure how to manage it. Health-status trends, patient goals, and team responsibilities contribute to care planning, but they do not substitute for condition-specific evidence-based guidance.