CCM Care Planning and Coordination 3

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?

Accepted Answer

Develop a unified care plan that addresses physical and behavioral health simultaneously

Answer

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?

Accepted Answer

To establish measurable, time-bound objectives that guide and evaluate care progress

Answer

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?

Accepted Answer

Identify a legal surrogate decision-maker and facilitate goals-of-care discussion

Answer

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?

Accepted Answer

Lack of timely follow-up appointment and inadequate transition planning

Answer

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?

Accepted Answer

Assess barriers to adherence and connect the patient with a diabetes self-management education program

Answer

Effective self-management support requires identifying individual barriers and connecting patients with structured education programs to build skills and confidence.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Care Planning and Coordination 3