CCM Care Coordination & Patient Advocacy 3 — Questions and Answers
Question 1: The primary goal of post-acute care follow-up within 7 days of hospital discharge is to:
- Assess patient satisfaction with their hospital stay
- Reduce the risk of preventable 30-day readmissions (Correct answer)
- Verify that the patient received their discharge paperwork
- Confirm that all specialist referrals have been made
Correct answer: Reduce the risk of preventable 30-day readmissions
Early post-discharge follow-up is a key evidence-based intervention to identify and resolve issues that lead to preventable 30-day hospital readmissions.
Question 2: Social determinants of health (SDOH) screening in care management is primarily intended to:
- Satisfy regulatory documentation requirements
- Identify non-clinical barriers that affect health outcomes (Correct answer)
- Determine the patient's eligibility for government benefits
- Assign the patient a risk stratification score
Correct answer: Identify non-clinical barriers that affect health outcomes
SDOH screening identifies factors like housing instability, food insecurity, and transportation barriers that directly impact a patient's ability to follow their care plan.
Question 3: A care manager working with a terminally ill patient who wants to remain at home should prioritize referral to:
- Inpatient palliative care unit
- Home hospice services (Correct answer)
- Long-term acute care hospital
- Outpatient oncology clinic
Correct answer: Home hospice services
Home hospice services align with the patient's goal of remaining at home while providing comfort-focused care, symptom management, and family support.
Question 4: Under HIPAA, a care manager may share a patient's protected health information (PHI) with a family member without written authorization when:
- The family member is the patient's next of kin
- The patient is present and verbally agrees to the disclosure (Correct answer)
- The information is limited to diagnosis only
- The family member provides proof of relationship
Correct answer: The patient is present and verbally agrees to the disclosure
HIPAA permits disclosure to family members when the patient is present, has capacity, and verbally agrees or does not object to the sharing of information.
Question 5: Which intervention is most effective in improving medication adherence in patients with multiple chronic conditions?
- Increasing the frequency of prescription refill reminders
- Simplifying the medication regimen and providing pill organizers (Correct answer)
- Switching all medications to generic equivalents
- Requiring monthly pharmacy pick-up as a compliance check
Correct answer: Simplifying the medication regimen and providing pill organizers
Regimen simplification and practical tools like pill organizers directly address the cognitive and logistical barriers that most commonly cause non-adherence in complex patients.
Question 6: A care manager identifies that a patient has been seeing three different physicians who are all prescribing opioids. The care manager's first responsibility is to:
- Report the patient to law enforcement for drug-seeking behavior
- Notify all three physicians immediately without informing the patient
- Consult the state prescription drug monitoring program (PDMP) and discuss findings with the primary provider (Correct answer)
- Discharge the patient from care management for non-compliance
Correct answer: Consult the state prescription drug monitoring program (PDMP) and discuss findings with the primary provider
Consulting the PDMP and coordinating with the primary provider is the appropriate clinical and advocacy-based response that addresses patient safety without prematurely judging the patient.
Question 7: In the context of care coordination, 'care fragmentation' refers to:
- A patient receiving care from providers who do not communicate or share information (Correct answer)
- A patient who refuses to follow a unified care plan
- A care manager who manages too many patients simultaneously
- An insurance plan that limits specialist referrals
Correct answer: A patient receiving care from providers who do not communicate or share information
Care fragmentation occurs when multiple providers deliver services in isolation, leading to duplicated tests, conflicting instructions, and increased risk of adverse events.
CCM Care Coordination & Patient Advocacy 3
The primary goal of post-acute care follow-up within 7 days of hospital discharge is to: