RN
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Registered Nurse
Created by Scolari Consulting
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Purpose of the Course
This course prepares RNs to recognize early warning signs, take timely action, and coordinate seamlessly with the IDT—ensuring participants receive safe, connected, and person-centered care across every setting.
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Module 2
Module 1
Module 3
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Module 1
Role Overview & Daily Practice
A New Day Begins
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It’s 7:00 a.m. Mindy, a seasoned RN in the PACE program, takes a quiet sip of coffee as she reviews her schedule for the day.
Click on each item in Mindy’s schedule to learn why it matters.
Wound care isn’t just a task—it’s an opportunity for holistic assessment. While cleaning and dressing the wound, you’re also checking circulation, healing progress, and pain levels. You educate the participant and their caregiver, preventing infection and unnecessary hospitalizations.
The Interdisciplinary Team (IDT) huddle is where real coordination happens. It’s your moment to bring in clinical updates, share red flags, and advocate for changes in the care plan. As the RN, your input ensures care decisions are timely, relevant, and person-centered.
Home visits reveal what the clinic can’t—fall risks, hygiene, nutrition, and med adherence. You might catch early red flags like unopened mail or caregiver fatigue. It’s about trust, safety, and seeing the full picture.
Care Planning Huddle with the IDT
Wound Dressing at the Center
A Home Visit
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MODULE 1
RN Role Overview & Daily Practice
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A New Day Begins
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You shift between home visits, emergencies, and charting—balancing real-time care with long-term planning.
You pivot
You’re not alone. You co-create care with the IDT, participants, and caregivers—every insight helps shape outcomes.
You collaborate
You guide participants, support families, mentor peers, and speak up when something’s off. Leadership shows in moments big and small.
You lead
You’re the clinical anchor. Your vigilance and follow-through prevent crises and keep care plans running smoothly.
Keep participants safe—and the care system flowing
MODULE 1
RN Role Overview & Daily Practice
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your role in action
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“Clinical Connector”
You tie it all together You bring participant observations to the IDT, shaping a care plan that reflects real-time needs.
“You Notice Early”
Missed appointments or a tired smileIt could signal depression, illness, or caregiver burnout. You spot changes before they become crises.
“Whole-Person Observation”
It’s more than vitals You assess emotional tone, mobility, safety risks, and social support—every encounter matters.
MODULE 1
RN Role Overview & Daily Practice
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what you actually do
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Assessments
chronic conditions
Initial, semi-annual, and change-in-condition assessments are the backbone of care. They inform the care plan, shape IDT decisions, and track participant progress over time.
You stay ahead of issues like hypertension, diabetes, and fall risk—tracking trends, noticing red flags, and preventing escalation.
care transitions
care plan updates
You ensure smooth handoffs from hospital to home, SNF to Day Center—making sure no detail is lost and no risk goes unnoticed.
What you learn on visits and in conversations directly informs updates to nursing interventions and IDT plans.
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MODULE 1
RN Role Overview & Daily Practice
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best practices
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Build Trust
Start with presence.
A calm tone, remembering details, or simply listening can open the door to honesty and better care.
make eye contact
It communicates that you see the person—not just the symptoms.
It helps participants feel safe, heard, and respected.
ask the follow-up question
“How have things been at home?”
“What’s been on your mind lately?”
One thoughtful question can uncover barriers or changes that go far beyond vitals.
MODULE 1
RN Role Overview & Daily Practice
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Documentation:Care Coordination in Action
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Care Action
What you did.
Example: “Contacted PCP”
Clear Observation
What you saw or heard.
Example: “+2 edema in ankles”
Collaborative Next Steps
What’s next and who’s involved.
Example: “Diuretic adjusted; will follow up in 48 hrs”
Clinical Interpretation
What it could indicate.
Example: “Likely fluid retention”
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MODULE 1
RN Role Overview & Daily Practice
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RED FLAGS
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Inside Mr. Taylor’s Living Room
Pill Organizer (Full)
Non-adherence to Meds: Missed doses may indicate cognitive decline, depression, or lack of support. Act before it leads to ER visits.
Participant’s Hands (Trembling)
Unsteady Hands: Could suggest neurological issues, medication side effects, or weakness. Ask questions and observe closely.
Bedside or Recliner Area
Changes in Sleep or Appetite: Sleep issues, missed meals, or changes in routines are often early signs of physical or emotional health decline.
Doorway or Calendar
Missed Day Center Visits: Missing routine check-ins may signal depression, transportation issues, or caregiver burnout.
Caregiver in the Background
Caregiver Stress or Withdrawal: Look for silence, irritability, or lack of engagement—these are signs the caregiver needs support too.
MODULE 1
RN Role Overview & Daily Practice
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mistakes that hurtAND HOW TO AVOID THEM
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Document right after each encounter.Timely notes reduce errors and support care continuity.
Use your checklist—even for short visits.You never know what small risk could become a big problem.
Confirm or report it. When in doubt, escalate concerns to the IDT or supervisor.
Assumed Someone Else Would Follow Up
Delayed Documentation
Skipped a Full Assessment
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Why it matters:
Good notes guide great care—
and prevent audit issues down the line.
MODULE 1
RN Role Overview & Daily Practice
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Real-Life StoryGloria’s Turning Point
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Mindy trusted her instinct, acted on it, and documented with clarity
Title
What changed the outcome?
Use this side to give more information about a topic.
Subtitle
MODULE 1
RN Role Overview & Daily Practice
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MODULE 1
RN Role Overview & Daily Practice
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MODULE 1
RN Role Overview & Daily Practice
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MODULE 1
RN Role Overview & Daily Practice
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Module 2
Module 1
Module 3
Module 4
Module 2
IDT Participation & Collaboration
A Missed Cue in the Meeting
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RN insights are critical. If they go undocumented or unspoken, outcomes suffer.
Documentation Spotlight
What Went Wrong Mindy observed changes, but:
Lesson:
Didn’t document them using the EHR
*Flip Card to Learn
Didn’t raise her concern during the IDT
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MODULE 2
IDT Participation & Collaboration
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Example Using the 4C Formula
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Example
Example
Example
Example
“Indicates possible cognitive decline or medication-related issue.”
“Pending MSW follow-up for cognitive assessment.”
“Notified caregiver, reinforced safety protocols.”
“Participant walked slowly and appeared confused about direction of travel.”
Here you can put an important title
Here you can put an important title
4C Step
4C Step
4C Step
4C Step
Collaborative Next Steps
Clear Observation
Care Action Taken
Clinical Interpretation
Contextualize your topic
Contextualize your topic
Write a short description here
Write a short description here
Compliance ReminderUnder 42 CFR §460.104, the RN must ensure the care plan reflects any new or worsening condition. That starts with timely, structured documentation.
🛡️
MODULE 2
IDT Participation & Collaboration
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best practices
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Best Practice
Close the loop
Best Practice
Speak with confidence
Best Practice
Respect all disciplines
Best Practice
Prepare before the meeting
Best Practice
Advocate for safety
MODULE 2
IDT Participation & Collaboration
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Common Mistakes &How to Avoid Them
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Why It Happens
Why It Happens
Why It Happens
Unclear roles
Doubting your input
Lack of structure
How to Fix It
How to Fix It
How to Fix It
Mistake
Mistake
Mistake
Check shared notes and clarify who follows up
Say: “Before we move on, I have something clinically important…”
Use the 4C Formula for clarity and clinical strength
Waiting too long to speak
Assuming someone else reported it
Vague updates (“She seemed off”)
Why It Happens
Why It Happens
Time pressure or habit
Fear of conflict
How to Fix It
How to Fix It
Mistake
Mistake
Document outcomes immediately after the meeting
Frame it around safety: “This could pose a risk unless we…”
Avoiding disagreement
Failing to document team decisions
MODULE 2
IDT Participation & Collaboration
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red flags
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That IDT CommunicationIs Breaking Down
RN remains silent in IDT
Why It MattersCritical clinical input is lost
Preventable hospitalizations
Why It MattersMissed opportunities to escalate or modify the care plan
Team members give conflicting input
Why It MattersSign of unclear communication or lack of documentation
No follow-up after IDT decision
Why It MattersCare plan may not be executed—puts participants at risk
Outdated nursing assessments
Why It MattersTeam is operating without updated clinical information
MODULE 2
IDT Participation & Collaboration
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Crucial RN InteractionsWithin the IDT
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Task/Role
Coordination with Therapists
Care Plan Meeting Participation
Bring updates, raise concerns, review interventions
Align therapy goals with nursing assessments
Communication with PCP
Communication with HCC or CNA
Escalate medical issues, confirm treatment plans
Ensure daily care needs are addressed and documented
Collaboration with MSW
Documentation in EHR
Log all findings, team decisions, and care coordination
Address psychosocial needs and caregiver support
SBAR Use in Handoffs
Provide structured, efficient updates during transitions or shift changes
MODULE 2
IDT Participation & Collaboration
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Document It or Lose It
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Documentation Spotlight – Full 4C Breakdown
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Mini-Scenario: “Document It or Lose It”
You notice a participant becoming quiet, slow, and forgetful. You casually mention it to the MSW—but never document it. Two weeks later, the participant falls. The family asks, “Why didn’t anyone notice?”
Clear Observation (Objective facts only — no interpretations yet)
Care Action Taken (Immediate steps you performed)
Key Takeaway
Her insight would have been visible to the entire IDT before the decision to reduce visits.This could have prevented the fall and hospitalization.
Clinical Interpretation (What these findings could indicate)
Collaborative Next Steps (Planned follow-ups & team involvement)
MODULE 2
IDT Participation & Collaboration
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MODULE 2
IDT Participation & Collaboration
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IDT Participation & Collaboration
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MODULE 2
IDT Participation & Collaboration
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Module 3
Module 4
Module 3
Care Coordination Acrossthe Continuum of Care
featured case
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Mr. Daniels:CHF, cognitive decline, SNF stay, return home
Documentation Spotlight: “Transitions are handoffs. If the handoff isn’t documented, the baton gets dropped—and the participant pays the price.”
MODULE 3
Care Coordination Across the Continuum of Care
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step 1
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Pre-Event / Preventive Phase
Mr. Daniels has been stable, but the Home Care Aide notes mild shortness of breath. You perform a home visit. BP is elevated, he’s missed his last Lasix dose, and his weight is up 4 lbs.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.104 Care plans must reflect any change in condition.
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MODULE 3
Care Coordination Across the Continuum of Care
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step 2: after hours
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After-Hours / Emergency Response
That night, the on-call nurse receives a call from Mr. Daniels’ daughter: “He’s gasping and confused.” EMS is dispatched.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.202The IDT must coordinate inpatient care and follow-up.
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Which part of the 4C Formula is missing in this example?
MODULE 3
Care Coordination Across the Continuum of Care
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step 3: hospital stay
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Mr. Daniels is admitted for CHF exacerbation. You confirm admission and start tracking labs and discharge readiness.
42 CFR §460.102IDT must integrate hospital updates into care planning.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
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MODULE 3
Care Coordination Across the Continuum of Care
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step 4: snf stay
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Mr. Daniels is discharged to SNF for short-term rehab. You review his orders, connect with SNF staff, and prep the IDT for return planning.
42 CFR §460.210PACE must ensure contracted SNFs follow care and communication protocols.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
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MODULE 3
Care Coordination Across the Continuum of Care
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step 5: return home
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Mr. Daniels returns home. You perform a nursing visit within 48 hours.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.104Post-discharge care plans must be reassessed and updated.
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MODULE 3
Care Coordination Across the Continuum of Care
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key takeaways
Click on each item to learn why it matters
Mr. Daniels returns home. You perform a nursing visit within 48 hours.
RNs lead the loop across transitions.
Documentation makes your actions visible and verifiable.
Every care setting requires RN judgment, follow-up, and communication.
Use the 4C Formula to ensure continuity and clarity.
Good documentation = better participant outcomes and audit success.
MODULE 3
Care Coordination Across the Continuum of Care
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MODULE 3
Care Coordination Across the Continuum of Care
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MODULE 3
Care Coordination Across the Continuum of Care
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MODULE 3
Care Coordination Across the Continuum of Care
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Module 4
Module 4
Real-World Practice & Application
objectives
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MODULE 4
Real-World Practice & Application
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- Age: 84
- Diagnosis: Hypertension, osteoarthritis, early dementia
- Setting: PACE Day Center and Home
- Primary RN: Mindy
- Other Key Players: PCP (Dr. Ramirez), MSW (Vanessa), PT (Greg), Daughter/Caregiver (Lucía)
Scenario
Mrs. Ortega
Continue
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MODULE 4
Real-World Practice & Application
decision point 1
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Home Visit Observation
Next Steps:
You perform a scheduled home visit on a rainy Monday afternoon. Mrs. Ortega answers the door slowly. She seems distracted and withdrawn. The apartment smells faintly of urine. Her blood pressure is elevated. When asked about her medications, she hesitates, then says, “Lucía helps sometimes… I think I took the morning one?” Lucía, her daughter and caregiver, is home but seems rushed. When you ask a few follow-up questions, she cuts in with “We’ve been managing fine.”
PAUSE AND REFLECT
DOCUMENTATION
MODULE 4
Real-World Practice & Application
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decision point 2
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Next Steps:
Day Center Follow-Up
Two days later, Mrs. Ortega attends the Day Center. She walks slowly, keeps to herself, and has new bruising on her right hand. When you ask about it, she says: “I fall sometimes, but Lucía says I’m just being dramatic.”The scheduler reports that Lucía hasn’t returned calls about upcoming appointments.
PAUSE AND REFLECT
DOCUMENTATION
MODULE 4
Real-World Practice & Application
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decision point 3
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Coordinating the IDT Response
Next Steps:
Later that day, you meet with Vanessa (MSW), who confirms Lucía has been missing calls. Greg (PT) reports worsening balance. Dr. Ramirez believes Mrs. Ortega’s cognitive symptoms are progressing. The team considers increasing home services—but no one has formally updated the care plan.
PAUSE AND REFLECT
DOCUMENTATION
MODULE 4
Real-World Practice & Application
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Compare the itemsin this table
Best Practice Guidance Table
MODULE 4
Real-World Practice & Application
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Reflection & Key Takeaways
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Key Takeaways:
“In PACE nursing, small details are rarely small. They are often the first threads in a much larger story—one that can end in recovery or in preventable harm.”
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Early Recognition Matters
Collaboration Saves Times and Lives
Documentation is Your Voice
Use the 4C Formula to make it clear, actionable, and team-ready.
Subtle signs can be the start of major changes.
The IDT can only respond to what they know.
MODULE 4
Real-World Practice & Application
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MODULE 4
Real-World Practice & Application
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Real-World Practice & Application
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MODULE 4
Real-World Practice & Application
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Evaluation
Instruction:True or False
question 1
EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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question 3
EVALUATION
Registered Nurse (RN)
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question 4
EVALUATION
Registered Nurse (RN)
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Instruction:True or False
question 5
EVALUATION
Registered Nurse (RN)
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question 6
EVALUATION
Registered Nurse (RN)
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question 7
EVALUATION
Registered Nurse (RN)
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question 8
EVALUATION
Registered Nurse (RN)
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Instruction:Multiple Choice
question 9
EVALUATION
Registered Nurse (RN)
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Instruction:Multiple Choice
question 10
EVALUATION
Registered Nurse (RN)
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Congratulations!
You’ve successfully completed your course—well done! Your commitment to learning, growing and improving your skills has truly paid off. By finishing this course, you’ve taken an important step in building new knowledge and strengthening your professional development. Keep up the great work, and remember that every skill you gain is an investment in your future.
Any questions?
👏
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
- Monitor hospital course
- Communicate with discharge planner and PACE PCP
- Prepare for post-acute follow-up
- Complete a focused nursing assessment
- Educate participant and caregiver on warning signs
- Notify PCP and document findings
- Update care plan if intervention is needed
What is your immediate clinical concern?
- What environmental or caregiver-related red flags are present?
- Who should you communicate with—and how quickly?
- What and how should you document this visit?
Documentation Spotlight – 4C Example:
- Clear Observation: Elevated BP, uncertainty about meds, urine odor in home.
- Clinical Interpretation: Possible med mismanagement, cognitive decline, caregiver stress.
- Care Action: Escalated to PCP and MSW, recommended medication review.
- Collaborative Next Steps: Notified IDT, requested reassessment, suggested MSW home follow-up.
✅ Proper documentation here could trigger timely intervention and prevent decline.❌ Vague notes risk missing the window for early action.
(Immediate steps you performed)
“Discussed safety precautions with caregiver, emphasizing supervision during ambulation.Reviewed medication schedule and importance of adherence. Encouraged use of nightlight in hallway to improve nighttime visibility.”
Why it works:
- Shows you acted before escalation
- Addresses environmental, caregiver, and medical factors
- Records participant and caregiver education
Documentation Spotlight:Document:
- Clinical concerns from all disciplines.
- Summary of team meeting or communications.
- Plan revisions (e.g., more home visits, MSW check-ins).
- Caregiver strain and actions taken (respite, referrals).
✅ Full IDT documentation ensures alignment and meets 42 CFR §460.104.❌ Missing documentation leaves no record for oversight or continuity.
Pause and Reflect
- Do these signs suggest functional decline, possible neglect, or both?
- What is your duty under elder abuse reporting laws and PACE protocols?
- Who needs to be alerted immediately?
- What language should you use in your clinical notes?
📌 Documentation Spotlight : “Failure to reconcile medications post-SNF = one of the top causes of readmission. Chart it. Check it. Confirm it.”4C Note Sample:
- Clear Observation: “Participant on new beta-blocker. Reports dizziness during PT.”
- Clinical Interpretation: “Possible side effect—monitor closely.”
- Care Action: “Flagged for PCP review. Spoke to SNF nurse.”
- Collaborative Steps: “Shared with IDT via SBAR; return date pending.”
Identify
Both clinical and environmental red flags
Communicate Effectively
Across disciplines and with family caregivers
📌 Documentation Spotlight: “The return-home note is he most under-documented step in transitions. It should tell the story of what changed, what’s needed, and what’s next.4C Note Sample:
- Clear Observation: “Participant walking independently but tires quickly. BP stable. Meds present but not organized.”
- Clinical Interpretation: “Stable recovery with need for med management support.”
- Care Action: “Reinforced med schedule. Called RN, PCP or PharmD for pillbox refill.”
- Collaborative Steps: “Flagged IDT for HCC referral to reinforce med adherence.”
Practice
Review recent notes and bring specific clinical concerns
Practice
MSWs, PTs, CNAs—all bring valuable insight. Listen and contribute.
“On-call notes aren’t a formality—they’re the first record of an acute event. If no one reads your note tomorrow, that’s on the system. If there’s no note to read, that’s on you.”
- Reassess vitals, function, cognition, home safety
- Reconcile medications
- Educate participant and family
- Update EHR and alert IDT to any changes
(Objective facts only — no interpretations yet)
“During home visit on 3/12, participant ambulated with slowed pace and widened stance. Stopped twice during 15-foot walk from living room to kitchen, appearing unsure of direction. Repeated question, ‘Where are we going?’ twice in five minutes. Missed three evening doses of metformin, as evidenced by pill organizer check.”
Why it works:
- Uses specific, measurable facts (dates, number of missed doses, description of gait)
- Avoids vague terms like “seemed confused” without context
- Includes environmental cues (pill organizer)
📝 Documentation Spotlight (Example Note): “Admitted 3/5 with CHF exacerbation. Receiving IV diuretics. Anticipated discharge 3/8. Will need home safety check and medication reconciliation.”“Track. Connect. Prepare.”Your hospital tracking notes are what inform the home visit prep. Don’t just copy/paste—synthesize.
- Perform SNF chart review and status checks
- Reconcile meds
- Coordinate Full-team coordination covers every aspect of care—medical, functional, nutritional, and psychosocial—ensuring smooth SNF transitions and reducing readmission risk.
(What these findings could indicate)
“Observed gait changes and disorientation suggest possible progression of cognitive impairment or acute delirium.Missed metformin doses could contribute to fluctuating blood glucose, potentially worsening confusion and increasing fall risk.”
Why it works:
- Links objective observations to possible causes
- Connects physical and cognitive changes to medical implications
- Positions the RN as the clinical connector between raw data and potential impact
(Planned follow-ups & team involvement)
“Will notify PCP of new gait and cognitive changes for further evaluation.Recommend PT reassessment before altering Day Center schedule. Request MSW follow-up to assess caregiver stress and ability to support medication adherence. Will recheck wound healing progress and reassess gait at next home visit (3/19).”
Why it works:
- Aligns with IDT collaboration
- Shows multi-disciplinary involvement
- Documents specific timelines
4C Formula Example:
- Clear Observation: “BP 164/94, 4 lb weight gain since last week. SOB on exertion.”
- Clinical Interpretation: “Signs and symptoms of fluid retention.”
- Care Action: “Provided med education. Called PCP; Lasix PRN order received.”
- Collaborative Steps: “Documented in EHR; flagged for IDT review tomorrow.”
Pause and Reflect
- What is your role in triggering an urgent IDT reassessment?
- How do you make sure the care plan reflects current needs?
- What follow-up is needed with Lucía as caregiver?
Document
In a way that drives timely IDT action
Documentation Spotlight:
- Use direct quotes: “I fall sometimes, but Lucía says I’m just being dramatic.”
- Note bruising details: exact location, size, and coloration.
- Include functional changes: activity refusal, emotional withdrawal.
- Alert MSW and PCP immediately; document notification.
✅ Supports elder abuse reporting and compliance with 42 CFR §460.102.❌ Omitting quotes or injury details can undermine interventions and legal protection.
Practice
Present clear observations and clinical reasoning—not just chart entries.
Ensure Compliance
With PACE regulations and elder protection laws
Practice
Document and alert IDT pre- and post-meeting; use SBAR for clarity.
“Received call about participant SOB. Sent to ER. Will follow up.” ❌ Missing: Clinical interpretation, collaborative steps, and follow-through plan.
Practice
Speak up—even when uncomfortable. Protect the participant above all else.
- Triage via phone, advise on emergency response
- Log call in clinical notes
- Notify PACE Center team and IDT the next morning
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RN
Continue
Registered Nurse
Created by Scolari Consulting
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Welcome to Your Course!
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This course is designed to be interactive and engaging. To get the most out of it, please remember:
Answer Quiz
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These elements on the screen—will guide you, share info, and help you move forward.
Enjoy your learning journey—we’re here to support you every step of the way!
Purpose of the Course
This course prepares RNs to recognize early warning signs, take timely action, and coordinate seamlessly with the IDT—ensuring participants receive safe, connected, and person-centered care across every setting.
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Module 2
Module 1
Module 3
Module 4
Module 1
Role Overview & Daily Practice
A New Day Begins
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It’s 7:00 a.m. Mindy, a seasoned RN in the PACE program, takes a quiet sip of coffee as she reviews her schedule for the day.
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Wound care isn’t just a task—it’s an opportunity for holistic assessment. While cleaning and dressing the wound, you’re also checking circulation, healing progress, and pain levels. You educate the participant and their caregiver, preventing infection and unnecessary hospitalizations.
The Interdisciplinary Team (IDT) huddle is where real coordination happens. It’s your moment to bring in clinical updates, share red flags, and advocate for changes in the care plan. As the RN, your input ensures care decisions are timely, relevant, and person-centered.
Home visits reveal what the clinic can’t—fall risks, hygiene, nutrition, and med adherence. You might catch early red flags like unopened mail or caregiver fatigue. It’s about trust, safety, and seeing the full picture.
Care Planning Huddle with the IDT
Wound Dressing at the Center
A Home Visit
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MODULE 1
RN Role Overview & Daily Practice
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A New Day Begins
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You shift between home visits, emergencies, and charting—balancing real-time care with long-term planning.
You pivot
You’re not alone. You co-create care with the IDT, participants, and caregivers—every insight helps shape outcomes.
You collaborate
You guide participants, support families, mentor peers, and speak up when something’s off. Leadership shows in moments big and small.
You lead
You’re the clinical anchor. Your vigilance and follow-through prevent crises and keep care plans running smoothly.
Keep participants safe—and the care system flowing
MODULE 1
RN Role Overview & Daily Practice
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your role in action
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“Clinical Connector”
You tie it all together You bring participant observations to the IDT, shaping a care plan that reflects real-time needs.
“You Notice Early”
Missed appointments or a tired smileIt could signal depression, illness, or caregiver burnout. You spot changes before they become crises.
“Whole-Person Observation”
It’s more than vitals You assess emotional tone, mobility, safety risks, and social support—every encounter matters.
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RN Role Overview & Daily Practice
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what you actually do
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Assessments
chronic conditions
Initial, semi-annual, and change-in-condition assessments are the backbone of care. They inform the care plan, shape IDT decisions, and track participant progress over time.
You stay ahead of issues like hypertension, diabetes, and fall risk—tracking trends, noticing red flags, and preventing escalation.
care transitions
care plan updates
You ensure smooth handoffs from hospital to home, SNF to Day Center—making sure no detail is lost and no risk goes unnoticed.
What you learn on visits and in conversations directly informs updates to nursing interventions and IDT plans.
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RN Role Overview & Daily Practice
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best practices
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Build Trust
Start with presence. A calm tone, remembering details, or simply listening can open the door to honesty and better care.
make eye contact
It communicates that you see the person—not just the symptoms. It helps participants feel safe, heard, and respected.
ask the follow-up question
“How have things been at home?” “What’s been on your mind lately?” One thoughtful question can uncover barriers or changes that go far beyond vitals.
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RN Role Overview & Daily Practice
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Documentation:Care Coordination in Action
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Care Action
What you did.
Example: “Contacted PCP”
Clear Observation
What you saw or heard.
Example: “+2 edema in ankles”
Collaborative Next Steps
What’s next and who’s involved.
Example: “Diuretic adjusted; will follow up in 48 hrs”
Clinical Interpretation
What it could indicate.
Example: “Likely fluid retention”
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RN Role Overview & Daily Practice
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RED FLAGS
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Inside Mr. Taylor’s Living Room
Pill Organizer (Full)
Non-adherence to Meds: Missed doses may indicate cognitive decline, depression, or lack of support. Act before it leads to ER visits.
Participant’s Hands (Trembling)
Unsteady Hands: Could suggest neurological issues, medication side effects, or weakness. Ask questions and observe closely.
Bedside or Recliner Area
Changes in Sleep or Appetite: Sleep issues, missed meals, or changes in routines are often early signs of physical or emotional health decline.
Doorway or Calendar
Missed Day Center Visits: Missing routine check-ins may signal depression, transportation issues, or caregiver burnout.
Caregiver in the Background
Caregiver Stress or Withdrawal: Look for silence, irritability, or lack of engagement—these are signs the caregiver needs support too.
MODULE 1
RN Role Overview & Daily Practice
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mistakes that hurtAND HOW TO AVOID THEM
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Document right after each encounter.Timely notes reduce errors and support care continuity.
Use your checklist—even for short visits.You never know what small risk could become a big problem.
Confirm or report it. When in doubt, escalate concerns to the IDT or supervisor.
Assumed Someone Else Would Follow Up
Delayed Documentation
Skipped a Full Assessment
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Why it matters: Good notes guide great care— and prevent audit issues down the line.
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RN Role Overview & Daily Practice
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Real-Life StoryGloria’s Turning Point
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Mindy trusted her instinct, acted on it, and documented with clarity
Title
What changed the outcome?
Use this side to give more information about a topic.
Subtitle
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RN Role Overview & Daily Practice
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IDT Participation & Collaboration
A Missed Cue in the Meeting
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RN insights are critical. If they go undocumented or unspoken, outcomes suffer.
Documentation Spotlight
What Went Wrong Mindy observed changes, but:
Lesson:
Didn’t document them using the EHR
*Flip Card to Learn
Didn’t raise her concern during the IDT
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IDT Participation & Collaboration
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Example Using the 4C Formula
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Example
Example
Example
Example
“Indicates possible cognitive decline or medication-related issue.”
“Pending MSW follow-up for cognitive assessment.”
“Notified caregiver, reinforced safety protocols.”
“Participant walked slowly and appeared confused about direction of travel.”
Here you can put an important title
Here you can put an important title
4C Step
4C Step
4C Step
4C Step
Collaborative Next Steps
Clear Observation
Care Action Taken
Clinical Interpretation
Contextualize your topic
Contextualize your topic
Write a short description here
Write a short description here
Compliance ReminderUnder 42 CFR §460.104, the RN must ensure the care plan reflects any new or worsening condition. That starts with timely, structured documentation.
🛡️
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IDT Participation & Collaboration
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best practices
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Best Practice
Close the loop
Best Practice
Speak with confidence
Best Practice
Respect all disciplines
Best Practice
Prepare before the meeting
Best Practice
Advocate for safety
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IDT Participation & Collaboration
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Common Mistakes &How to Avoid Them
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Why It Happens
Why It Happens
Why It Happens
Unclear roles
Doubting your input
Lack of structure
How to Fix It
How to Fix It
How to Fix It
Mistake
Mistake
Mistake
Check shared notes and clarify who follows up
Say: “Before we move on, I have something clinically important…”
Use the 4C Formula for clarity and clinical strength
Waiting too long to speak
Assuming someone else reported it
Vague updates (“She seemed off”)
Why It Happens
Why It Happens
Time pressure or habit
Fear of conflict
How to Fix It
How to Fix It
Mistake
Mistake
Document outcomes immediately after the meeting
Frame it around safety: “This could pose a risk unless we…”
Avoiding disagreement
Failing to document team decisions
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IDT Participation & Collaboration
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red flags
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That IDT CommunicationIs Breaking Down
RN remains silent in IDT
Why It MattersCritical clinical input is lost
Preventable hospitalizations
Why It MattersMissed opportunities to escalate or modify the care plan
Team members give conflicting input
Why It MattersSign of unclear communication or lack of documentation
No follow-up after IDT decision
Why It MattersCare plan may not be executed—puts participants at risk
Outdated nursing assessments
Why It MattersTeam is operating without updated clinical information
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IDT Participation & Collaboration
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Crucial RN InteractionsWithin the IDT
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Task/Role
Coordination with Therapists
Care Plan Meeting Participation
Bring updates, raise concerns, review interventions
Align therapy goals with nursing assessments
Communication with PCP
Communication with HCC or CNA
Escalate medical issues, confirm treatment plans
Ensure daily care needs are addressed and documented
Collaboration with MSW
Documentation in EHR
Log all findings, team decisions, and care coordination
Address psychosocial needs and caregiver support
SBAR Use in Handoffs
Provide structured, efficient updates during transitions or shift changes
MODULE 2
IDT Participation & Collaboration
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Document It or Lose It
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Documentation Spotlight – Full 4C Breakdown
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Mini-Scenario: “Document It or Lose It”
You notice a participant becoming quiet, slow, and forgetful. You casually mention it to the MSW—but never document it. Two weeks later, the participant falls. The family asks, “Why didn’t anyone notice?”
Clear Observation (Objective facts only — no interpretations yet)
Care Action Taken (Immediate steps you performed)
Key Takeaway
Her insight would have been visible to the entire IDT before the decision to reduce visits.This could have prevented the fall and hospitalization.
Clinical Interpretation (What these findings could indicate)
Collaborative Next Steps (Planned follow-ups & team involvement)
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IDT Participation & Collaboration
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Care Coordination Acrossthe Continuum of Care
featured case
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Mr. Daniels:CHF, cognitive decline, SNF stay, return home
Documentation Spotlight: “Transitions are handoffs. If the handoff isn’t documented, the baton gets dropped—and the participant pays the price.”
MODULE 3
Care Coordination Across the Continuum of Care
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step 1
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Pre-Event / Preventive Phase
Mr. Daniels has been stable, but the Home Care Aide notes mild shortness of breath. You perform a home visit. BP is elevated, he’s missed his last Lasix dose, and his weight is up 4 lbs.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.104 Care plans must reflect any change in condition.
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Care Coordination Across the Continuum of Care
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step 2: after hours
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After-Hours / Emergency Response
That night, the on-call nurse receives a call from Mr. Daniels’ daughter: “He’s gasping and confused.” EMS is dispatched.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.202The IDT must coordinate inpatient care and follow-up.
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Which part of the 4C Formula is missing in this example?
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Care Coordination Across the Continuum of Care
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step 3: hospital stay
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Mr. Daniels is admitted for CHF exacerbation. You confirm admission and start tracking labs and discharge readiness.
42 CFR §460.102IDT must integrate hospital updates into care planning.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
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Care Coordination Across the Continuum of Care
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step 4: snf stay
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Mr. Daniels is discharged to SNF for short-term rehab. You review his orders, connect with SNF staff, and prep the IDT for return planning.
42 CFR §460.210PACE must ensure contracted SNFs follow care and communication protocols.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
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Care Coordination Across the Continuum of Care
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step 5: return home
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Mr. Daniels returns home. You perform a nursing visit within 48 hours.
ComplianceTie-In
RN Responsibilities
DocumentationSpotlight
42 CFR §460.104Post-discharge care plans must be reassessed and updated.
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Care Coordination Across the Continuum of Care
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key takeaways
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Mr. Daniels returns home. You perform a nursing visit within 48 hours.
RNs lead the loop across transitions.
Documentation makes your actions visible and verifiable.
Every care setting requires RN judgment, follow-up, and communication.
Use the 4C Formula to ensure continuity and clarity.
Good documentation = better participant outcomes and audit success.
MODULE 3
Care Coordination Across the Continuum of Care
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Care Coordination Across the Continuum of Care
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Real-World Practice & Application
objectives
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Real-World Practice & Application
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Scenario
Mrs. Ortega
Continue
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MODULE 4
Real-World Practice & Application
decision point 1
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Home Visit Observation
Next Steps:
You perform a scheduled home visit on a rainy Monday afternoon. Mrs. Ortega answers the door slowly. She seems distracted and withdrawn. The apartment smells faintly of urine. Her blood pressure is elevated. When asked about her medications, she hesitates, then says, “Lucía helps sometimes… I think I took the morning one?” Lucía, her daughter and caregiver, is home but seems rushed. When you ask a few follow-up questions, she cuts in with “We’ve been managing fine.”
PAUSE AND REFLECT
DOCUMENTATION
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Real-World Practice & Application
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decision point 2
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Next Steps:
Day Center Follow-Up
Two days later, Mrs. Ortega attends the Day Center. She walks slowly, keeps to herself, and has new bruising on her right hand. When you ask about it, she says: “I fall sometimes, but Lucía says I’m just being dramatic.”The scheduler reports that Lucía hasn’t returned calls about upcoming appointments.
PAUSE AND REFLECT
DOCUMENTATION
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decision point 3
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Coordinating the IDT Response
Next Steps:
Later that day, you meet with Vanessa (MSW), who confirms Lucía has been missing calls. Greg (PT) reports worsening balance. Dr. Ramirez believes Mrs. Ortega’s cognitive symptoms are progressing. The team considers increasing home services—but no one has formally updated the care plan.
PAUSE AND REFLECT
DOCUMENTATION
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Real-World Practice & Application
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Compare the itemsin this table
Best Practice Guidance Table
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Real-World Practice & Application
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Reflection & Key Takeaways
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Key Takeaways:
“In PACE nursing, small details are rarely small. They are often the first threads in a much larger story—one that can end in recovery or in preventable harm.”
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Early Recognition Matters
Collaboration Saves Times and Lives
Documentation is Your Voice
Use the 4C Formula to make it clear, actionable, and team-ready.
Subtle signs can be the start of major changes.
The IDT can only respond to what they know.
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Evaluation
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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EVALUATION
Registered Nurse (RN)
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question 9
EVALUATION
Registered Nurse (RN)
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question 10
EVALUATION
Registered Nurse (RN)
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Congratulations!
You’ve successfully completed your course—well done! Your commitment to learning, growing and improving your skills has truly paid off. By finishing this course, you’ve taken an important step in building new knowledge and strengthening your professional development. Keep up the great work, and remember that every skill you gain is an investment in your future.
Any questions?
👏
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
What is your immediate clinical concern?
Documentation Spotlight – 4C Example:
- Clear Observation: Elevated BP, uncertainty about meds, urine odor in home.
- Clinical Interpretation: Possible med mismanagement, cognitive decline, caregiver stress.
- Care Action: Escalated to PCP and MSW, recommended medication review.
- Collaborative Next Steps: Notified IDT, requested reassessment, suggested MSW home follow-up.
✅ Proper documentation here could trigger timely intervention and prevent decline.❌ Vague notes risk missing the window for early action.(Immediate steps you performed)
“Discussed safety precautions with caregiver, emphasizing supervision during ambulation.Reviewed medication schedule and importance of adherence. Encouraged use of nightlight in hallway to improve nighttime visibility.”
Why it works:
Documentation Spotlight:Document:
- Clinical concerns from all disciplines.
- Summary of team meeting or communications.
- Plan revisions (e.g., more home visits, MSW check-ins).
- Caregiver strain and actions taken (respite, referrals).
✅ Full IDT documentation ensures alignment and meets 42 CFR §460.104.❌ Missing documentation leaves no record for oversight or continuity.Pause and Reflect
📌 Documentation Spotlight : “Failure to reconcile medications post-SNF = one of the top causes of readmission. Chart it. Check it. Confirm it.”4C Note Sample:
Identify
Both clinical and environmental red flags
Communicate Effectively
Across disciplines and with family caregivers
📌 Documentation Spotlight: “The return-home note is he most under-documented step in transitions. It should tell the story of what changed, what’s needed, and what’s next.4C Note Sample:
Practice
Review recent notes and bring specific clinical concerns
Practice
MSWs, PTs, CNAs—all bring valuable insight. Listen and contribute.
“On-call notes aren’t a formality—they’re the first record of an acute event. If no one reads your note tomorrow, that’s on the system. If there’s no note to read, that’s on you.”
(Objective facts only — no interpretations yet)
“During home visit on 3/12, participant ambulated with slowed pace and widened stance. Stopped twice during 15-foot walk from living room to kitchen, appearing unsure of direction. Repeated question, ‘Where are we going?’ twice in five minutes. Missed three evening doses of metformin, as evidenced by pill organizer check.”
Why it works:
📝 Documentation Spotlight (Example Note): “Admitted 3/5 with CHF exacerbation. Receiving IV diuretics. Anticipated discharge 3/8. Will need home safety check and medication reconciliation.”“Track. Connect. Prepare.”Your hospital tracking notes are what inform the home visit prep. Don’t just copy/paste—synthesize.
(What these findings could indicate)
“Observed gait changes and disorientation suggest possible progression of cognitive impairment or acute delirium.Missed metformin doses could contribute to fluctuating blood glucose, potentially worsening confusion and increasing fall risk.”
Why it works:
(Planned follow-ups & team involvement)
“Will notify PCP of new gait and cognitive changes for further evaluation.Recommend PT reassessment before altering Day Center schedule. Request MSW follow-up to assess caregiver stress and ability to support medication adherence. Will recheck wound healing progress and reassess gait at next home visit (3/19).”
Why it works:
4C Formula Example:
Pause and Reflect
Document
In a way that drives timely IDT action
Documentation Spotlight:
- Use direct quotes: “I fall sometimes, but Lucía says I’m just being dramatic.”
- Note bruising details: exact location, size, and coloration.
- Include functional changes: activity refusal, emotional withdrawal.
- Alert MSW and PCP immediately; document notification.
✅ Supports elder abuse reporting and compliance with 42 CFR §460.102.❌ Omitting quotes or injury details can undermine interventions and legal protection.Practice
Present clear observations and clinical reasoning—not just chart entries.
Ensure Compliance
With PACE regulations and elder protection laws
Practice
Document and alert IDT pre- and post-meeting; use SBAR for clarity.
“Received call about participant SOB. Sent to ER. Will follow up.” ❌ Missing: Clinical interpretation, collaborative steps, and follow-through plan.
Practice
Speak up—even when uncomfortable. Protect the participant above all else.