Care Transition Management Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Care Transition Management flashcards as text
Which federal program provides transition assistance specifically for Medicare beneficiaries moving from inpatient facilities back to the community?
Answer: Transitional Care Management (TCM) services
CMS Transitional Care Management (TCM) CPT codes 99495 and 99496 reimburse providers for structured follow-up within 7 or 14 days of discharge from an inpatient facility.
A case manager notices a patient was readmitted three times in six months always within the first week of discharge. The MOST likely root cause to investigate is:
Answer: Inadequate post-discharge follow-up and support in the first 72 hours
Repeated early readmissions strongly suggest a gap in immediate post-discharge support, such as no primary care follow-up, medication access issues, or caregiver breakdown in the first 72 hours.
The Transitional Care Model (TCM) developed by Mary Naylor at the University of Pennsylvania is distinguished by its use of:
Answer: Advanced practice nurses who follow high-risk older adults across care settings
Naylor's TCM uses advanced practice nurses (APNs) as the primary coordinator, following high-risk elders from hospital through home to reduce readmissions and costs.
Which document is considered the cornerstone of effective care transition communication between settings?
Answer: A comprehensive, timely discharge summary sent to the next provider
A timely, complete discharge summary with diagnosis, medications, pending results, and follow-up plan is the foundational communication tool for safe care transitions.
A case manager is working with a patient who has limited English proficiency transitioning to home health care. Which action is MOST important?
Answer: Arranging for a trained medical interpreter for all transition-related communications
Federal law (Title VI of the Civil Rights Act) requires that healthcare organizations provide trained medical interpreters, not family members, for patients with limited English proficiency.
Which of the following interventions is MOST effective in reducing preventable 30-day readmissions for high-risk patients?
Answer: A structured post-discharge phone call within 48-72 hours by a trained clinician
Evidence consistently shows that a structured nurse telephone call within 48-72 hours post-discharge catches early warning signs and is one of the most cost-effective readmission reduction strategies.
When developing a care transition plan, which element BEST reflects the principle of patient-centered care?
Answer: Incorporating the patient's and caregiver's goals, values, and preferences into the plan
Patient-centered care requires that transition plans align with what matters most to the patient and family, not just clinical criteria or cost.