MCQ Quiz: Transitions of Care

Transitions of Care (TOC) encompasses a broad range of services designed to ensure the safe and effective coordination and continuity of healthcare as patients move between different locations or levels of care. For pharmacists, TOC is a critical area of practice focused on preventing medication-related problems, which are a leading cause of hospital readmissions. Key pharmacist-led activities include performing thorough medication reconciliation, providing clear and concise discharge counseling, and conducting post-discharge follow-up. This quiz will test your knowledge on the essential components, challenges, and best practices involved in pharmacist-managed Transitions of Care, a vital service for improving patient safety.

1. What is the primary goal of Transitions of Care (TOC) services?

• a) To increase the length of hospital stays.
• b) To ensure the safe and effective transfer of patients between care settings, reducing medication errors and readmissions.
• c) To reduce the number of medications a patient is taking.
• d) To exclusively manage the billing process between different facilities.

Answer: b) To ensure the safe and effective transfer of patients between care settings, reducing medication errors and readmissions.

2. The process of creating the most accurate list possible of all medications a patient is taking is known as:

• a) A comprehensive medication review (CMR).
• b) A therapeutic interchange.
• c) Obtaining a Best Possible Medication History (BPMH).
• d) A prior authorization.

Answer: c) Obtaining a Best possible Medication History (BPMH).

3. Which of the following is considered the most reliable source when obtaining a BPMH?

• a) The patient’s memory alone.
• b) The hospital’s electronic medical record (EMR) alone.
• c) The patient’s outpatient pharmacy records alone.
• d) A combination of multiple sources, including the patient/caregiver, pharmacy records, and medical records.

Answer: d) A combination of multiple sources, including the patient/caregiver, pharmacy records, and medical records.

4. A pharmacist compares the medications a patient was taking at home to the medications ordered upon admission to the hospital. A drug the patient was taking at home was not ordered in the hospital. This is an example of what type of medication discrepancy?

• a) Omission
• b) Commission
• c) Duplication
• d) Incorrect dose

Answer: a) Omission

5. Which patient population is at the highest risk for adverse drug events during transitions of care?

• a) Young adults with a single acute condition.
• b) Elderly patients with polypharmacy, multiple comorbidities, and low health literacy.
• c) Patients admitted for elective, minor surgery.
• d) Healthy pediatric patients.

Answer: b) Elderly patients with polypharmacy, multiple comorbidities, and low health literacy.

6. The “teach-back” method is a crucial component of discharge counseling. It involves:

• a) Having the patient read the medication leaflet back to the pharmacist.
• b) Asking the patient to explain in their own words how they will take their medication.
• c) Giving the patient a quiz on their medications.
• d) Showing the patient a video about their condition.

Answer: b) Asking the patient to explain in their own words how they will take their medication.

7. Project RED (Re-Engineered Discharge) is an evidence-based model for improving the hospital discharge process. A key component of this model is:

• a) Ensuring the patient receives a follow-up appointment before leaving the hospital.
• b) Providing a handwritten list of medications.
• c) Limiting counseling to less than 5 minutes.
• d) Discharging all patients before noon.

Answer: a) Ensuring the patient receives a follow-up appointment before leaving the hospital.

8. A “warm handoff” in transitions of care refers to:

• a) Sending a fax to the patient’s primary care provider.
• b) Leaving a voicemail for the outpatient pharmacy.
• c) A direct, real-time conversation between the inpatient provider and the outpatient provider to transfer care.
• d) Giving the patient their discharge paperwork.

Answer: c) A direct, real-time conversation between the inpatient provider and the outpatient provider to transfer care.

9. What is a primary purpose of a post-discharge follow-up phone call from a pharmacist?

• a) To schedule the patient’s next hospital admission.
• b) To confirm the patient’s home address.
• c) To assess medication adherence, identify adverse drug events, and resolve any medication-related problems.
• d) To sell the patient over-the-counter supplements.

Answer: c) To assess medication adherence, identify adverse drug events, and resolve any medication-related problems.

10. A patient was taking warfarin at home, but it was held during their hospital stay for a surgical procedure. The discharge summary does not mention restarting the warfarin. This is a common type of discrepancy known as:

• a) Therapeutic duplication.
• b) A formulary substitution.
• c) An intentional, undocumented discrepancy.
• d) An unintentional discrepancy due to omission.

Answer: d) An unintentional discrepancy due to omission.

11. The three core steps of the medication reconciliation process are:

• a) Prescribing, Dispensing, and Administration.
• b) Verification, Clarification, and Reconciliation.
• c) Admission, Transfer, and Discharge.
• d) Diagnosis, Treatment, and Follow-up.

Answer: b) Verification, Clarification, and Reconciliation.

12. When providing discharge counseling, it is most effective to:

• a) Use complex medical terminology to show expertise.
• b) Focus on the 3-5 most important medication-related instructions.
• c) Provide information on every possible side effect for all medications.
• d) Speak only to the family member, not the patient.

Answer: b) Focus on the 3-5 most important medication-related instructions.

13. A patient is being discharged from the hospital to a skilled nursing facility (SNF). This movement represents:

• a) An intratrahospital transfer.
• b) An interfacility transition of care.
• c) A discharge to home.
• d) An admission from the community.

Answer: b) An interfacility transition of care.

14. Which of the following is a significant barrier to effective transitions of care?

• a) Over-communication between healthcare providers.
• b) Patients having high health literacy.
• c) Poor communication and incomplete transfer of information between inpatient and outpatient settings.
• d) The use of standardized discharge forms.

Answer: c) Poor communication and incomplete transfer of information between inpatient and outpatient settings.

15. A pharmacist calls a patient 3 days after discharge and learns the patient could not afford their new, expensive anticoagulant. What is the pharmacist’s most appropriate action?

• a) Tell the patient to stop taking all their medications.
• b) Inform the patient that cost is not a valid reason to miss doses.
• c) Contact the prescriber to discuss more affordable, therapeutically appropriate alternatives and explore patient assistance programs.
• d) Do nothing, as cost is the patient’s responsibility.

Answer: c) Contact the prescriber to discuss more affordable, therapeutically appropriate alternatives and explore patient assistance programs.

16. The “brown bag” review is a medication reconciliation technique where the patient:

• a) Brings in a brown bag lunch for the healthcare team.
• b) Writes down all their medications on a brown paper bag.
• c) Brings all of their medications, including OTCs and supplements, in a bag to their appointment for review.
• d) Receives their discharge medications in a brown paper bag.

Answer: c) Brings all of their medications, including OTCs and supplements, in a bag to their appointment for review.

17. In the medication reconciliation step of “clarification,” the pharmacist’s role is to:

• a) Create a list of the patient’s home medications.
• b) Investigate and resolve any discrepancies found between the home medication list and the admission orders.
• c) Document the final, reconciled medication list in the patient’s chart.
• d) Counsel the patient on their new medications.

Answer: b) Investigate and resolve any discrepancies found between the home medication list and the admission orders.

18. A key performance measure for the success of a transitions of care program is:

• a) The number of pharmacists employed by the hospital.
• b) The 30-day hospital readmission rate.
• c) The average length of a patient’s hospital stay.
• d) The number of prescriptions dispensed at discharge.

Answer: b) The 30-day hospital readmission rate.

19. When counseling a patient at discharge, which of the following is an example of an open-ended question?

• a) “Do you have any questions?”
• b) “You understand how to take this, right?”
• c) “What will you tell your spouse about this new heart medication?”
• d) “Are you going to take this medication as prescribed?”

Answer: c) “What will you tell your spouse about this new heart medication?”

20. A patient’s home medication list includes “water pill,” “sugar pill,” and “little white pill.” This highlights the need for the pharmacist to:

• a) Guess which medications the patient is referring to.
• b) Use probing questions and other sources (like the pharmacy) to identify the specific drugs, strengths, and doses.
• c) Document the medications exactly as the patient stated.
• d) Tell the patient their list is not helpful.

Answer: b) Use probing questions and other sources (like the pharmacy) to identify the specific drugs, strengths, and doses.

21. Project BOOST is a TOC initiative that stands for:

• a) Bettering Outpatient Outcomes with Standard Treatment.
• b) Better Outcomes for Older Adults through Safe Transitions.
• c) Bringing Onboard Optimal Systems for Transitions.
• d) Building Our Outpatient Services Team.

Answer: b) Better Outcomes for Older Adults through Safe Transitions.

22. An effective discharge medication list for a patient should ideally include:

• a) Only the new medications started in the hospital.
• b) Only the medications the patient was taking before admission.
• c) A list of all medications to be taken after discharge, including which home medications to stop, continue, or change.
• d) Only the brand names of the medications.

Answer: c) A list of all medications to be taken after discharge, including which home medications to stop, continue, or change.

23. A patient at high risk for readmission often has which of the following characteristics?

• a) A prescription for 10 or more medications (polypharmacy).
• b) A recent admission for heart failure.
• c) Low health literacy.
• d) All of the above.

Answer: d) All of the above.

24. The final step of medication reconciliation is to:

• a) Create the initial list of home medications.
• b) Communicate the new, reconciled list to the patient and future healthcare providers.
• c) Identify discrepancies.
• d) Clarify the dose of each medication.

Answer: b) Communicate the new, reconciled list to the patient and future healthcare providers.

25. A pharmacist is counseling a patient on a new, complicated insulin regimen. What is the most important element to confirm before the patient leaves?

• a) That the patient knows the color of the insulin pen.
• b) That the patient can demonstrate how to dial the correct dose and perform a practice injection.
• c) That the patient has watched a video about diabetes.
• d) That the patient promises to be adherent.

Answer: b) That the patient can demonstrate how to dial the correct dose and perform a practice injection.

26. Which of the following is a common reason for medication discrepancies at hospital discharge?

• a) Intentional therapeutic changes made in the hospital are not clearly communicated.
• b) Formulary substitutions made in the hospital are not reconciled with home medications.
• c) Medications started for acute issues in the hospital are unintentionally continued at discharge.
• d) All of the above.

Answer: d) All of the above.

27. The term “medication discrepancy” refers to:

• a) Any difference between two or more medication lists for the same patient.
• b) An adverse drug event.
• c) A medication that is too expensive.
• d) A patient’s refusal to take a medication.

Answer: a) Any difference between two or more medication lists for the same patient.

28. An effective strategy for simplifying a medication regimen at discharge is:

• a) Switching all medications to the most expensive brand names.
• b) Using once-daily formulations where possible.
• c) Prescribing every medication with a “take as needed” instruction.
• d) Adding several over-the-counter supplements to the regimen.

Answer: b) Using once-daily formulations where possible.

29. During a post-discharge follow-up call, a patient reports feeling dizzy since starting a new blood pressure medication. The pharmacist should first:

• a) Tell the patient to stop the medication immediately.
• b) Assess the severity of the dizziness, ask about recent blood pressure readings, and inquire how the patient is taking the medication.
• c) Tell the patient dizziness is a normal side effect and to ignore it.
• d) Advise the patient to double the dose.

Answer: b) Assess the severity of the dizziness, ask about recent blood pressure readings, and inquire how the patient is taking the medication.

30. The “medication-use process” in the hospital involves prescribing, transcribing, dispensing, and which final step?

• a) Administration
• b) Billing
• c) Reconciliation
• d) Counseling

Answer: a) Administration

31. A patient with low health literacy would benefit most from which type of discharge instructions?

• a) A 10-page document written at a college reading level.
• a) Verbal instructions only with no written material.
• c) Instructions with simple language, large font, and clear pictures or pictograms.
• d) A link to a medical journal article about their condition.

Answer: c) Instructions with simple language, large font, and clear pictures or pictograms.

32. The “reconciliation” part of the medication reconciliation process involves:

• a) Making clinical decisions, in conjunction with the physician, to resolve any identified discrepancies.
• b) Verifying the patient’s insurance information.
• c) Creating a list of the patient’s allergies.
• d) Dispensing the medications.

Answer: a) Making clinical decisions, in conjunction with the physician, to resolve any identified discrepancies.

33. An example of an interprofessional TOC team would include a physician, a nurse, a case manager, and a:

• a) Hospital administrator
• b) Pharmacist
• c) Medical student
• d) Billing clerk

Answer: b) Pharmacist

34. A patient is being discharged. Their home medication was lisinopril 20 mg daily. The hospital discharge list says “Resume all home medications.” However, their blood pressure was low in the hospital and the team intended to stop the lisinopril. This is an example of a failure in:

• a) Patient counseling
• b) Communication of the discharge plan
• c) Pharmacy dispensing
• d) Patient adherence

Answer: b) Communication of the discharge plan

35. One of the most significant benefits of a pharmacist-led TOC program is:

• a) An increase in pharmacy revenue.
• b) A reduction in medication-related problems and preventable hospital readmissions.
• c) A decrease in the number of medications prescribed.
• d) Shorter hospital stays for all patients.

Answer: b) A reduction in medication-related problems and preventable hospital readmissions.

36. When taking a medication history, it is important to ask specifically about:

• a) Over-the-counter (OTC) medications.
• b) Herbal supplements and vitamins.
• c) As-needed (PRN) medications.
• d) All of the above.

Answer: d) All of the above.

37. A discharge summary is often the primary tool for communicating with outpatient providers. A common flaw with this tool is that it is often:

• a) Too detailed and specific.
• b) Not available at the time of the patient’s first follow-up appointment.
• c) Written by the pharmacist.
• d) Only available in a paper format.

Answer: b) Not available at the time of the patient’s first follow-up appointment.

38. The “medication action plan” (MAP) given to a patient at the end of a comprehensive medication review is:

• a) A legally binding contract.
• b) A patient-centric document outlining what the patient needs to do to manage their medications.
• c) A bill for pharmacy services.
• d) A prescription for new medications.

Answer: b) A patient-centric document outlining what the patient needs to do to manage their medications.

39. A patient’s daughter calls the pharmacist after her father’s discharge, confused about which medications are new and which he should stop taking. This indicates a failure in:

• a) The medication reconciliation process.
• b) The discharge counseling process.
• c) The communication of a clear, final medication list.
• d) All of the above.

Answer: d) All of the above.

40. A pharmacist identifies that a patient was prescribed two different medications from the same therapeutic class upon discharge. This is what type of medication discrepancy?

• a) Omission
• b) Therapeutic duplication
• c) Wrong dose
• d) Wrong frequency

Answer: b) Therapeutic duplication

41. The ideal time to perform medication reconciliation is:

• a) Only at discharge.
• b) At every transition of care, including admission, transfer, and discharge.
• c) One week after the patient has gone home.
• d) It is not a necessary process.

Answer: b) At every transition of care, including admission, transfer, and discharge.

42. Which of the following is an example of an “intentional” medication discrepancy?

• a) A nurse forgets to administer a dose of a medication.
• b) A physician purposefully changes a patient’s home blood pressure medication to a different one on the hospital’s formulary.
• c) A pharmacy dispenses the wrong strength of a medication.
• d) A patient forgets to list one of their home medications.

Answer: b) A physician purposefully changes a patient’s home blood pressure medication to a different one on the hospital’s formulary.

43. A pharmacist is preparing for a post-discharge follow-up call. What is the first thing they should do?

• a) Call the patient immediately.
• b) Review the patient’s hospital stay, discharge summary, and final medication list.
• c) Assume all medications were filled and taken correctly.
• d) Call the patient’s insurance company.

Answer: b) Review the patient’s hospital stay, discharge summary, and final medication list.

44. To improve health literacy during discharge counseling, a pharmacist should avoid:

• a) Using pictograms.
• b) Using medical jargon.
• c) Speaking slowly and clearly.
• d) Asking the patient if they have questions.

Answer: b) Using medical jargon.

45. The “verification” step of medication reconciliation involves:

• a) Making changes to the medication regimen.
• b) Documenting the final medication list.
• c) Collecting the list of medications the patient is currently taking.
• d) Counseling the patient on their new regimen.

Answer: c) Collecting the list of medications the patient is currently taking.

46. Which of the following is a key challenge when conducting medication reconciliation for a patient with dementia?

• a) The patient is an unreliable historian, making collaboration with caregivers and other sources essential.
• b) These patients are rarely on multiple medications.
• c) Dementia improves medication adherence.
• d) There are no specific challenges.

Answer: a) The patient is an unreliable historian, making collaboration with caregivers and other sources essential.

47. A pharmacist is preparing to counsel a patient being discharged with 12 medications. A good strategy to improve patient understanding and retention is to:

• a) Discuss all 12 medications in alphabetical order as quickly as possible.
• b) Group medications by indication (e.g., “These are for your heart,” “These are for your diabetes”) and focus on the most critical changes.
• c) Tell the patient to read the leaflets when they get home.
• d) Only discuss the new medications.

Answer: b) Group medications by indication (e.g., “These are for your heart,” “These are for your diabetes”) and focus on the most critical changes.

48. Why is it important to ask a patient how they are actually taking their medication, rather than just how it is prescribed?

• a) To identify potential non-adherence or misunderstanding.
• b) To confirm the prescriber wrote the prescription correctly.
• c) It is not important; the prescription directions are all that matter.
• d) To bill for extra counseling time.

Answer: a) To identify potential non-adherence or misunderstanding.

49. A patient is being transferred from the ICU to a general medical floor. This is an example of:

• a) An interfacility transition.
• b) An intrahospital transition.
• c) A discharge.
• d) An admission.

Answer: b) An intrahospital transition.

50. The ultimate responsibility for ensuring a patient understands their discharge medication plan lies with:

• a) The patient alone.
• b) The discharging physician alone.
• c) The entire healthcare team, through a coordinated and collaborative effort.
• d) The outpatient pharmacy that fills the prescriptions.

Answer: c) The entire healthcare team, through a coordinated and collaborative effort.