Domain III: Systems


This section discusses providing care that uses resources prudently and minimizes unnecessary discomfort and disruption for patients/residents (e.g. limited nonessential vital signs and blood sugar checks).  This section describes identified rationale for and uses of key patient/resident databases (e.g. the Minimum Data Set - MDS), in care planning, facility reimbursement, and monitoring quality.  This section discusses determinations of appropriate levels of care for patients/residents including identification of those who could benefit from a different level of care.  This section reviews performing functions and tasks that support safe transitions of care.  This section presents content on working effectively with other members of the IDT, including the medical director, in providing care based on understanding and valuing the general roles, responsibilities, and levels of knowledge and training for those of various disciplines.  This module discusses informing patients/residents and their families of their healthcare options and potential impact on personal finances by incorporating knowledge of payment models relevant to the PA/LTC setting.


Hours: 3.00


Certificates provided by accrediting body (1 Match)

American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine


Course Details

Course Code: REL-AHC-AMDA-DOM3
Hours: 3
Type: Online Course
Content Expiration Date: 5/31/2021
Learning Objectives:
Describe the basic components of the MDS.
List the MDS’ main uses for clinical decision making, care planning, facility reimbursement, and quality assessment and improvement in the SNF/NF setting.
Describe the specific data and screening tools present in the MDS and their applicability to patient care.
Compare and contrast the capabilities (including scope of services) and limitations of the sites of care within the PA/LTC continuum.
Given a patient scenario, select the appropriate levels and sites of care considering the patient/resident’s medical needs, preferences, and values
Perform medication reconciliation on admission and discharge.
Describe and demonstrate the benefits of direct communication with relevant care providers at the previous or next site of care.
Develop or modify an existing plan of care by taking into account the patient baseline functional and clinical status, the hospital course, and the current clinical state.
Organize appropriate medical discharge documentation that communicates pertinent clinical information in a timely fashion with relevant care providers both on admission and discharge.
Describe the components of and rationale for an advanced care planning process.
Identify and present the information needed by patients, families, and other care sites to help make relevant decisions about patient/residents’ scope of care and life-sustaining treatments upon change of condition or transfer to another care setting, including completion of pre-hospital Do Not Resuscitate or POLST Paradigm forms where available.
Evaluate the current medical plan of care for the patient on admission and determine the need for modification with periodic reassessment at routine regulatory visits and upon changes of patient/resident condition.
Perform a patient history and physical examination in a timely fashion based on patient acuity and regulatory requirements, and adjust the plan of care as appropriate.
Prior to patient/resident discharge provide medical input to the interdisciplinary team (IDT) and the patient/family in order to help to ensure a safe discharge plan.
Describe the scope of practice and role and responsibilities of the IDT members in the SNF/NF.
Explain payment models relevant to the PA/LTC setting including but not limited to Medicare, Medicaid, and Managed Care.
Explain to patients and families key considerations in balancing costs with scope of services in various PA/LTC settings.


3.1  Providing Prudent and Minimally Disruptive Care

3.2  Using Patient Databases in Clinical Practice

3.3  Determining Appropriate Levels of Care

3.4  Optimal Management of Care Transitions

3.5  Working Effectively with the Interdisciplinary Care Team

3.6  Understanding and Explaining the Impact of Finances on Care Decisions

Instructor: AMDA - The Society for Post-Acute and Long-Term Care Medicine

We are pleased to acknowledge the following contributors: Patricia L. Bach, PsyD, RN; Alva S. Baker, III, MD, CMDR; Daniel Bluestein, MD, MS, CMD; Bavid A. Brechtelsbauer, MD, CMD; Jeffrey B. Burl, MD, CMD; Amy Corcoran, MD CMD; Leonard Gelman, MD, CMD; Daniel Haimowitz, MD, FACP, CMD; Paul R. Katz, MD, CMD; Karyn Leible, MD, CMD; Meghan Lembeck, MD; James E. Lett, II, MD, CMDR; Steven A. Levenson, MD, CMD; Arif Nazir, MD, CMD; Dallas Nelson, MD, FACP, CMD; Debra Saliba, MD, MPH; Karl E. Steinberg, MD, CMD; Joshua Uy, MD; Matthew S Wayne, MD, CMD; Heidi K. White, MD, MEd, CMD

Disclosure: AMDA - The Society for Post-Acute and Long-Term Care Medicine has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Physicians; in the following settings: Post-Acute Care.
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Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
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