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 tool is specifically designed to assess a patient's readiness for hospital discharge and likelihood of successful transition to the next care setting?
Answer: LACE Index
The LACE Index (Length of stay, Acuity, Comorbidities, Emergency visits) predicts 30-day readmission risk to guide discharge planning.
A case manager is coordinating a patient's transition from acute care to a skilled nursing facility. Which action is MOST critical to prevent medication errors during handoff?
Answer: Conducting medication reconciliation before transfer
Medication reconciliation at every care transition is the most critical step to identify and resolve discrepancies that cause adverse drug events.
The Care Transitions Intervention (CTI) model developed by Eric Coleman focuses primarily on which element?
Answer: Empowering patients through four pillars including self-management skills
Coleman's CTI builds patient and caregiver skills across four pillars: medication self-management, a personal health record, primary care follow-up, and knowing red flags.
Under CMS Hospital Readmissions Reduction Program (HRRP), hospitals face financial penalties for excessive readmissions within how many days for targeted conditions?
Answer: 30 days
HRRP penalizes hospitals for risk-adjusted 30-day readmission rates above the national average for conditions such as AMI, heart failure, COPD, and pneumonia.
A patient with heart failure is being discharged home. Which educational topic should the case manager prioritize to prevent early readmission?
Answer: Daily weight monitoring and when to call the provider
Teaching heart failure patients to weigh themselves daily and report sudden weight gain (fluid retention) is a primary strategy to prevent acute decompensation and readmission.
Which of the following BEST describes a 'warm handoff' in care transition practice?
Answer: A direct verbal introduction between the sending and receiving provider with the patient present
A warm handoff involves real-time, direct communication between providers—ideally with the patient present—to ensure continuity and reduce information gaps.
A patient is transitioning from an inpatient psychiatric unit to a community mental health center. Which barrier to successful transition should the case manager address FIRST?
Answer: Confirming the patient has a confirmed appointment and transportation before discharge
Ensuring a confirmed follow-up appointment with reliable transportation is the most immediate, actionable barrier to address before psychiatric discharge.