CCM Care Transition Management 2

Question 1

Which tool is specifically designed to assess a patient's readiness for hospital discharge and likelihood of successful transition to the next care setting?

Accepted Answer

LACE Index

Answer

The LACE Index (Length of stay, Acuity, Comorbidities, Emergency visits) predicts 30-day readmission risk to guide discharge planning.

Question 2

A case manager is coordinating a patient's transition from acute care to a skilled nursing facility. Which action is MOST critical to prevent medication errors during handoff?

Accepted Answer

Conducting medication reconciliation before transfer

Answer

Medication reconciliation at every care transition is the most critical step to identify and resolve discrepancies that cause adverse drug events.

Question 3

The Care Transitions Intervention (CTI) model developed by Eric Coleman focuses primarily on which element?

Accepted Answer

Empowering patients through four pillars including self-management skills

Answer

Coleman's CTI builds patient and caregiver skills across four pillars: medication self-management, a personal health record, primary care follow-up, and knowing red flags.

Question 4

Under CMS Hospital Readmissions Reduction Program (HRRP), hospitals face financial penalties for excessive readmissions within how many days for targeted conditions?

Accepted Answer

30 days

Answer

HRRP penalizes hospitals for risk-adjusted 30-day readmission rates above the national average for conditions such as AMI, heart failure, COPD, and pneumonia.

Question 5

A patient with heart failure is being discharged home. Which educational topic should the case manager prioritize to prevent early readmission?

Accepted Answer

Daily weight monitoring and when to call the provider

Answer

Teaching heart failure patients to weigh themselves daily and report sudden weight gain (fluid retention) is a primary strategy to prevent acute decompensation and readmission.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Care Transition Management 2