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 using the Chronic Care Model (CCM). Which component focuses on supporting patients to manage their own conditions between healthcare visits?
Answer: Self-management support
Self-management support empowers patients with skills, tools, and confidence to actively manage their chronic conditions in their daily lives.
A patient with end-stage renal disease is transitioning from in-center hemodialysis to home dialysis. Which care plan element is MOST critical for a safe transition?
Answer: Training competency verification for the patient and caregiver on home dialysis procedures
Verified training competency for both the patient and caregiver is the safety-critical prerequisite before transitioning to home dialysis.
Which federal legislation most directly established the legal framework for care coordination requirements in Medicare managed care plans?
Answer: The Affordable Care Act (ACA) of 2010
The ACA significantly expanded care coordination requirements, including provisions for accountable care organizations, medical homes, and care transitions programs within Medicare.
A case manager identifies that a patient's care plan includes duplicate laboratory testing ordered by two different specialists. What is the most appropriate action?
Answer: Facilitate communication between the specialists to eliminate redundant testing
Eliminating duplicative care through provider communication is a core care coordination function that reduces patient burden and unnecessary costs.
In population health management, which stratification level requires the most intensive case management interventions?
Answer: High-risk patients with multiple comorbidities, frequent hospitalizations, and complex social needs
Risk stratification directs the highest intensity resources toward complex, high-risk patients who will benefit most from intensive case management interventions.
A case manager is documenting a care plan for a patient with cancer who has elected palliative care. Which statement BEST reflects the role of the palliative care plan?
Answer: The palliative care plan focuses on symptom management and quality of life, which may run concurrently with curative treatment
Palliative care is specialized medical care focused on symptom relief and quality of life that can be provided alongside curative or active treatments at any stage.
When evaluating the effectiveness of a care plan, which outcome measure is MOST directly aligned with case management goals?
Answer: Reduction in avoidable emergency department visits and hospital readmissions
Reducing avoidable ED visits and readmissions reflects successful care coordination, improved self-management, and appropriate resource utilization—core case management goals.