Chronic Disease Management & Care Coordination Flashcards
7 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 7 Chronic Disease Management & Care Coordination flashcards as text
During a care transition, the 'teach-back method' is used PRIMARILY to:
Answer: Verify patient understanding by having them explain instructions in their own words
The teach-back method confirms patient comprehension by asking patients to repeat instructions in their own words, identifying and correcting misunderstandings before discharge.
Which of the following is a key difference between disease management and case management in chronic care?
Answer: Disease management targets populations with specific conditions; case management focuses on complex individual patients
Disease management applies population-level protocols to patients with a specific condition, while case management provides intensive, individualized coordination for complex high-risk patients.
A patient with uncontrolled hypertension reports that they cannot afford their antihypertensive medication. The MOST appropriate care coordinator action is to:
Answer: Connect the patient with pharmaceutical assistance programs, generic alternatives, or patient assistance resources
Connecting patients with pharmaceutical assistance programs, 340B programs, or generic alternatives directly addresses cost barriers to medication adherence.
The 'Triple Aim' framework in chronic care management focuses on improving:
Answer: Population health, patient experience, and per capita cost of care
The IHI Triple Aim framework simultaneously targets improving population health outcomes, enhancing individual patient experience, and reducing the per capita cost of healthcare.
When a care coordinator conducts a comprehensive needs assessment for a patient with multiple chronic conditions, which domain should ALWAYS be included?
Answer: Physical health, mental health, functional status, social support, and social determinants of health
A comprehensive chronic care needs assessment must address all dimensions of health including physical, mental, functional, social, and SDOH to identify the full scope of patient needs.
Evidence-based clinical practice guidelines for chronic disease management are BEST described as:
Answer: Systematically developed recommendations to assist clinical decision-making based on best available evidence
Clinical practice guidelines are systematically developed, evidence-based recommendations that guide—but do not replace—clinical judgment in managing specific conditions.
A care coordinator notes that a patient with chronic obstructive pulmonary disease (COPD) has never received a pneumococcal vaccine. The MOST appropriate action is to:
Answer: Flag the immunization gap, notify the care team, and facilitate the patient receiving the recommended vaccine
COPD patients are at high risk for pneumococcal pneumonia; the care coordinator's role is to close immunization gaps by flagging them and coordinating with the care team to ensure delivery.