Care Planning and Coordination 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 Planning and Coordination flashcards as text
A case manager is working with a patient who has both physical and behavioral health needs. Which approach best reflects integrated care planning?
Answer: Develop a unified care plan that addresses physical and behavioral health simultaneously
Integrated care planning addresses the interconnected nature of physical and behavioral health within a single, coordinated plan to achieve better overall outcomes.
Which of the following is a primary function of the SMART goal framework in care planning?
Answer: To establish measurable, time-bound objectives that guide and evaluate care progress
SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) provide clear benchmarks for evaluating whether care plan objectives are being met.
A newly hospitalized elderly patient has no advance directive. The patient is now cognitively impaired and cannot make decisions. What is the case manager's FIRST responsibility?
Answer: Identify a legal surrogate decision-maker and facilitate goals-of-care discussion
When a patient lacks decision-making capacity and has no advance directive, the case manager must first identify the appropriate surrogate decision-maker per state law.
Which care coordination barrier is MOST commonly associated with hospital readmission within 30 days?
Answer: Lack of timely follow-up appointment and inadequate transition planning
Research consistently shows that failure to schedule post-discharge follow-up and inadequate transition planning are the leading contributors to preventable 30-day readmissions.
A case manager is coordinating care for a patient with Type 2 diabetes who has poor medication adherence. Which intervention best addresses self-management support in the care plan?
Answer: Assess barriers to adherence and connect the patient with a diabetes self-management education program
Effective self-management support requires identifying individual barriers and connecting patients with structured education programs to build skills and confidence.
During care plan development, the case manager determines the patient's primary caregiver is experiencing burnout. What should be included in the care plan?
Answer: Incorporate respite care resources and caregiver support services into the plan
Caregiver well-being directly impacts patient outcomes; a comprehensive care plan addresses caregiver support needs, including respite services, to sustain the care relationship.
What is the primary purpose of a multidisciplinary care conference in the care coordination process?
Answer: To enable all team members to share perspectives and align on a unified care plan
Multidisciplinary care conferences bring together all providers to share clinical perspectives, resolve conflicts, and create a cohesive, patient-centered care plan.