CCM Care Planning and Coordination 3 — Questions and Answers
Question 1: A case manager is working with a patient who has both physical and behavioral health needs. Which approach best reflects integrated care planning?
- Address physical health needs first, then refer to behavioral health separately
- Develop a unified care plan that addresses physical and behavioral health simultaneously (Correct answer)
- Refer the patient to behavioral health and close the physical health case
- Treat each condition independently with separate care plans from different providers
Correct answer: Develop a unified care plan that addresses physical and behavioral health simultaneously
Integrated care planning addresses the interconnected nature of physical and behavioral health within a single, coordinated plan to achieve better overall outcomes.
Question 2: Which of the following is a primary function of the SMART goal framework in care planning?
- To prioritize the case manager's workload over patient needs
- To create vague, aspirational goals that motivate patients
- To establish measurable, time-bound objectives that guide and evaluate care progress (Correct answer)
- To document insurance authorization requirements
Correct answer: To establish measurable, time-bound objectives that guide and evaluate care progress
SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) provide clear benchmarks for evaluating whether care plan objectives are being met.
Question 3: A newly hospitalized elderly patient has no advance directive. The patient is now cognitively impaired and cannot make decisions. What is the case manager's FIRST responsibility?
- Make treatment decisions on the patient's behalf based on clinical judgment
- Identify a legal surrogate decision-maker and facilitate goals-of-care discussion (Correct answer)
- Proceed with the most aggressive treatment available
- Contact the hospital ethics committee immediately without further assessment
Correct answer: Identify a legal surrogate decision-maker and facilitate goals-of-care discussion
When a patient lacks decision-making capacity and has no advance directive, the case manager must first identify the appropriate surrogate decision-maker per state law.
Question 4: Which care coordination barrier is MOST commonly associated with hospital readmission within 30 days?
- Insufficient specialist referrals during the hospital stay
- Lack of timely follow-up appointment and inadequate transition planning (Correct answer)
- Too many discharge instructions given at once
- Failure to update the patient's demographic information
Correct answer: Lack of timely follow-up appointment and inadequate transition planning
Research consistently shows that failure to schedule post-discharge follow-up and inadequate transition planning are the leading contributors to preventable 30-day readmissions.
Question 5: A case manager is coordinating care for a patient with Type 2 diabetes who has poor medication adherence. Which intervention best addresses self-management support in the care plan?
- Increase the frequency of physician visits without addressing adherence barriers
- Provide the patient with a diabetes education pamphlet only
- Assess barriers to adherence and connect the patient with a diabetes self-management education program (Correct answer)
- Refer the patient to an endocrinologist without follow-up
Correct answer: Assess barriers to adherence and connect the patient with a diabetes self-management education program
Effective self-management support requires identifying individual barriers and connecting patients with structured education programs to build skills and confidence.
Question 6: During care plan development, the case manager determines the patient's primary caregiver is experiencing burnout. What should be included in the care plan?
- Remove the caregiver from the care team
- Ignore caregiver status as it is outside the case manager's scope
- Incorporate respite care resources and caregiver support services into the plan (Correct answer)
- Immediately place the patient in a facility
Correct answer: Incorporate respite care resources and caregiver support services into the plan
Caregiver well-being directly impacts patient outcomes; a comprehensive care plan addresses caregiver support needs, including respite services, to sustain the care relationship.
Question 7: What is the primary purpose of a multidisciplinary care conference in the care coordination process?
- To formally assign blame when care goals are not met
- To enable all team members to share perspectives and align on a unified care plan (Correct answer)
- To reduce the case manager's documentation burden
- To satisfy accreditation requirements only
Correct answer: To enable all team members to share perspectives and align on a unified care plan
Multidisciplinary care conferences bring together all providers to share clinical perspectives, resolve conflicts, and create a cohesive, patient-centered care plan.
CCM Care Planning and Coordination 3
A case manager is working with a patient who has both physical and behavioral health needs.
Which approach best reflects integrated care planning?