CCP Transitional Care & Care Transitions Flashcards
6 cards from real CCP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CCP Transitional Care & Care Transitions flashcards as text
A CCP conducting a post-discharge phone call discovers that a patient did not fill their discharge prescriptions. The BEST response is to:
Answer: Explore the barrier (cost, access, understanding) and coordinate resolution immediately
Identifying and resolving medication barriers immediately after discharge is critical to preventing adverse events and readmissions from gaps in therapy.
Which element is MOST important in a high-quality discharge summary for a patient with multiple chronic conditions?
Answer: Pending test results, follow-up instructions, reconciled medication list, and reason for hospitalization
High-quality discharge summaries must include the reconciled medication list, reason for admission, pending results, and clear follow-up instructions to ensure care continuity.
Naylor's Transitional Care Model (TCM) is BEST characterized by:
Answer: Advanced practice nurse-led coordination across settings with a focus on high-risk patients
Naylor's TCM uses advanced practice registered nurses to provide comprehensive, patient-centered transitional care across hospital, home, and outpatient settings for high-risk chronic patients.
When a patient is discharged to home with new home health services, the CCP should coordinate with the home health agency to ensure:
Answer: Shared care goals, updated medication list, and clear communication channels are established
Effective coordination with home health agencies requires sharing aligned care goals, an updated medication list, and establishing clear communication protocols to prevent fragmented care.
Which of the following is a 'red flag' symptom that a CCP should instruct a patient with CHF to monitor daily after hospital discharge?
Answer: Weight gain of more than 2–3 pounds in a single day or 5 pounds in a week
Rapid weight gain indicates fluid retention in CHF patients and is an early warning sign of decompensation that requires immediate clinical evaluation.
A CCP is designing a care transition program for a high-risk patient panel. Which metric BEST evaluates the program's effectiveness?
Answer: 30-day readmission rate and post-discharge follow-up visit completion rate
The 30-day readmission rate combined with follow-up visit completion rate are the most direct outcome measures of transitional care program effectiveness.