CCM - Certified Case Manager Care Transition Management Questions and Answers

Question 1

A case manager is preparing for the discharge of an older adult client with congestive heart failure, diabetes, and low health literacy.
According to the Coleman Care Transitions Intervention® (CTI), which of the following actions is MOST critical for the case manager (acting as a Transitions Coach®) to prioritize?

Accepted Answer

Empowering the client to understand and self-manage their medications using a personal health record.

Answer

Scheduling all follow-up appointments with the primary care physician and cardiologist.

Answer

Providing a complete list of all community resources for transportation and meal delivery.

Answer

Arranging for a home health aide to manage the client's medications for the first month.

Question 2

Which of the following is the PRIMARY purpose of medication reconciliation during a care transition?

Accepted Answer

To create a single, accurate list of all medications to avoid errors like omissions, duplications, or interactions.

Answer

To educate the patient on the side effects of each new medication.

Answer

To ensure the patient has affordable access to all prescribed medications.

Answer

To confirm that the patient's insurance plan covers the newly prescribed drugs.

Question 3

A case manager is implementing the Project RED (Re-Engineered Discharge) protocol for a client being discharged from the hospital. Which of the following is a key component specific to this model?

Accepted Answer

Providing the client with a written, easy-to-understand After Hospital Care Plan (AHCP).

Answer

A four-week program of home visits and phone calls by a Transitions Coach®.

Answer

Focusing exclusively on older adults with multiple chronic conditions.

Answer

A nurse-led intervention with a primary focus on long-term care management.

Question 4

When coordinating a client's transition from a skilled nursing facility (SNF) back to their home with home health services, which action by the case manager is MOST crucial for ensuring continuity of care?

Accepted Answer

Facilitating a warm handoff call between the SNF nurse and the incoming home health nurse.

Answer

Ensuring the client's durable medical equipment is delivered before they arrive home.

Answer

Providing the client's family with the home health agency's 24-hour contact number.

Answer

Confirming the client's first primary care appointment is scheduled within 14 days.

Question 5

The Transitional Care Model (TCM) developed by Mary Naylor is a nurse-led intervention that has consistently demonstrated reduced rehospitalizations. This model is specifically designed to target which patient population?

Accepted Answer

Older adults with multiple chronic conditions at high risk for poor outcomes.

Answer

All patients being discharged from an acute care hospital.

Answer

Pediatric patients with newly diagnosed chronic illnesses.

Answer

Patients recovering from elective, low-risk surgical procedures.

Question 6

A case manager is assessing a client prior to hospital discharge to identify the risk of a complicated care transition. Which of the following factors represents the HIGHEST risk for hospital readmission?

Accepted Answer

The client has a history of a previous hospital admission within the past 30 days.

Answer

The client lives in a rural area more than 30 miles from the hospital.

Answer

The client is over the age of 65 and has a new diagnosis of hypertension.

Answer

The client expressed mild anxiety about managing their care at home.