CCM Care Transition Management 2 — Questions and Answers
Question 1: Which tool is specifically designed to assess a patient's readiness for hospital discharge and likelihood of successful transition to the next care setting?
- LACE Index (Correct answer)
- PHQ-9
- Braden Scale
- Barthel Index
Correct answer: LACE Index
The LACE Index (Length of stay, Acuity, Comorbidities, Emergency visits) predicts 30-day readmission risk to guide discharge planning.
Question 2: A case manager is coordinating a patient's transition from acute care to a skilled nursing facility. Which action is MOST critical to prevent medication errors during handoff?
- Conducting medication reconciliation before transfer (Correct answer)
- Calling the receiving facility one hour before discharge
- Providing a general summary of the patient's diagnosis
- Asking the patient to remember all current medications
Correct answer: Conducting medication reconciliation before transfer
Medication reconciliation at every care transition is the most critical step to identify and resolve discrepancies that cause adverse drug events.
Question 3: The Care Transitions Intervention (CTI) model developed by Eric Coleman focuses primarily on which element?
- Empowering patients through four pillars including self-management skills (Correct answer)
- Providing 24/7 nurse hotline support for 90 days post-discharge
- Assigning a physician to follow the patient across all care settings
- Using telemedicine visits to replace all in-person follow-up
Correct answer: Empowering patients through four pillars including self-management skills
Coleman's CTI builds patient and caregiver skills across four pillars: medication self-management, a personal health record, primary care follow-up, and knowing red flags.
Question 4: Under CMS Hospital Readmissions Reduction Program (HRRP), hospitals face financial penalties for excessive readmissions within how many days for targeted conditions?
- 30 days (Correct answer)
- 14 days
- 60 days
- 90 days
Correct answer: 30 days
HRRP penalizes hospitals for risk-adjusted 30-day readmission rates above the national average for conditions such as AMI, heart failure, COPD, and pneumonia.
Question 5: A patient with heart failure is being discharged home. Which educational topic should the case manager prioritize to prevent early readmission?
- Daily weight monitoring and when to call the provider (Correct answer)
- Dietary preferences for hospital meal planning
- Transportation resources to the nearest pharmacy
- How to appeal insurance coverage decisions
Correct answer: Daily weight monitoring and when to call the provider
Teaching heart failure patients to weigh themselves daily and report sudden weight gain (fluid retention) is a primary strategy to prevent acute decompensation and readmission.
Question 6: Which of the following BEST describes a 'warm handoff' in care transition practice?
- A direct verbal introduction between the sending and receiving provider with the patient present (Correct answer)
- Faxing a complete medical record 24 hours before discharge
- Sending a discharge summary via secure email to the next provider
- Scheduling a follow-up appointment for the patient after discharge
Correct answer: A direct verbal introduction between the sending and receiving provider with the patient present
A warm handoff involves real-time, direct communication between providers—ideally with the patient present—to ensure continuity and reduce information gaps.
Question 7: A patient is transitioning from an inpatient psychiatric unit to a community mental health center. Which barrier to successful transition should the case manager address FIRST?
- Confirming the patient has a confirmed appointment and transportation before discharge (Correct answer)
- Reviewing the patient's insurance coverage for outpatient psychiatry
- Identifying whether the community center accepts new patients
- Documenting the patient's diagnosis in the transfer paperwork
Correct answer: Confirming the patient has a confirmed appointment and transportation before discharge
Ensuring a confirmed follow-up appointment with reliable transportation is the most immediate, actionable barrier to address before psychiatric discharge.
CCM Care Transition Management 2
Which tool is specifically designed to assess a patient's readiness for hospital discharge and likelihood of successful transition to the next care setting?