Certified Case Manager Care Transition Management 1 Flashcards
6 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 6 Certified Case Manager Care Transition Management 1 flashcards as text
Which component of the Care Transitions Intervention (CTI) model is considered the cornerstone of empowering patients during the post-discharge period?
Answer: Using a personal health record maintained by the patient
The CTI model developed by Eric Coleman centers on a patient-maintained personal health record (PHR) that the individual carries across all care settings, promoting self-management and continuity of information.
A case manager is reconciling a patient's medications at discharge and discovers a discrepancy between the inpatient medication list and the patient's home regimen. What is the MOST appropriate immediate action?
Answer: Clarify the discrepancy with the prescribing physician before discharge is completed
Medication discrepancies are a leading cause of adverse events after discharge. Resolving discrepancies with the prescribing physician prior to discharge prevents medication errors and reduces readmission risk.
Under the Re-Engineered Discharge (RED) toolkit, which action is specifically required to close the communication loop between the hospital and the patient's primary care provider?
Answer: Transmitting the discharge plan to the PCP before or on the day of discharge
The RED toolkit requires that the primary care provider receive the discharge plan on or before the day of discharge so the outpatient team is prepared to continue care without gaps.
A case manager is assessing a newly discharged patient for self-management ability. Which validated tool is MOST appropriate for evaluating a patient's activation level and readiness to manage their own health?
Answer: The Patient Activation Measure (PAM)
The Patient Activation Measure (PAM) quantifies a patient's knowledge, skills, and confidence in managing their health, making it the standard instrument for assessing self-management readiness during care transitions.
Which of the following best describes the role of a Transition Coach in the Coleman Care Transitions Intervention?
Answer: A skilled facilitator who helps patients develop self-advocacy skills across care settings
In the CTI model, the Transition Coach does not provide clinical care but instead works to build the patient's capacity to communicate with providers, manage medications, and recognize warning signs — empowering self-advocacy.
When evaluating a care transition program's effectiveness, which outcome metric MOST directly reflects the program's impact on reducing preventable readmissions?
Answer: The 30-day all-cause hospital readmission rate
The 30-day all-cause readmission rate is the primary benchmark used by CMS and quality improvement frameworks to evaluate care transition effectiveness, as it captures preventable returns attributable to gaps in the transition process.