CCP CCP Social Determinants of Health & Community Resources 2 — Questions and Answers
Question 1: Which SDOH domain is MOST directly linked to poor glycemic control in patients with type 2 diabetes?
- Transportation access
- Food insecurity (Correct answer)
- Educational attainment
- Employment status
Correct answer: Food insecurity
Food insecurity is most directly linked to poor glycemic control because patients may eat high-glycemic foods when healthy options are unavailable or unaffordable.
Question 2: A CCP notices a patient's chronic conditions are worsening despite adherence to medication. The CCP should assess for:
- A need for more aggressive pharmacotherapy only
- Underlying social stressors such as job loss or domestic stress (Correct answer)
- The patient's willingness to change physicians
- Increasing specialist co-pays as a barrier
Correct answer: Underlying social stressors such as job loss or domestic stress
Worsening health despite medication adherence often signals unaddressed social stressors that undermine overall wellness and self-management capacity.
Question 3: In the context of CCP practice, 'warm handoffs' to community health workers are used to:
- Transfer full clinical responsibility to non-clinical staff
- Facilitate personal introductions that increase trust and follow-through on referrals (Correct answer)
- Reduce costs by replacing physician visits
- Automate SDOH screening processes
Correct answer: Facilitate personal introductions that increase trust and follow-through on referrals
A warm handoff involves a personal introduction between the care professional and the community health worker, improving patient trust and referral completion rates.
Question 4: Which SDOH factor is MOST associated with increased emergency department utilization among chronic disease patients?
- Having a primary care physician
- Low health literacy combined with lack of social support (Correct answer)
- Participation in wellness programs
- Regular preventive care visits
Correct answer: Low health literacy combined with lack of social support
Patients with low health literacy and inadequate social support are significantly more likely to use the emergency department as a primary care source.
Question 5: When completing an SDOH screening, a CCP discovers a patient experiences intimate partner violence (IPV). The CCP must:
- Immediately report to law enforcement without patient consent
- Follow mandatory reporting laws and provide safe resource referrals per state guidelines (Correct answer)
- Document and take no further action to respect privacy
- Remove the patient from the chronic care program
Correct answer: Follow mandatory reporting laws and provide safe resource referrals per state guidelines
CCPs must comply with applicable mandatory reporting laws while offering trauma-informed support and safe resources such as hotlines and shelters.
Question 6: The 'Health Leads' model used in chronic care settings is designed to:
- Replace physician-led care with nurse practitioners
- Connect patients to community resources directly from the clinical encounter (Correct answer)
- Standardize electronic health record documentation
- Train patients to self-administer injections
Correct answer: Connect patients to community resources directly from the clinical encounter
The Health Leads model embeds trained advocates in clinical settings to connect patients with community resources that address SDOH during or immediately after clinical visits.
CCP CCP Social Determinants of Health & Community Resources 2
Which SDOH domain is MOST directly linked to poor glycemic control in patients with type 2 diabetes?