CCM Care Transition Management 3

Question 1

Which federal program provides transition assistance specifically for Medicare beneficiaries moving from inpatient facilities back to the community?

Accepted Answer

Transitional Care Management (TCM) services

Answer

CMS Transitional Care Management (TCM) CPT codes 99495 and 99496 reimburse providers for structured follow-up within 7 or 14 days of discharge from an inpatient facility.

Question 2

A case manager notices a patient was readmitted three times in six months always within the first week of discharge. The MOST likely root cause to investigate is:

Accepted Answer

Inadequate post-discharge follow-up and support in the first 72 hours

Answer

Repeated early readmissions strongly suggest a gap in immediate post-discharge support, such as no primary care follow-up, medication access issues, or caregiver breakdown in the first 72 hours.

Question 3

The Transitional Care Model (TCM) developed by Mary Naylor at the University of Pennsylvania is distinguished by its use of:

Accepted Answer

Advanced practice nurses who follow high-risk older adults across care settings

Answer

Naylor's TCM uses advanced practice nurses (APNs) as the primary coordinator, following high-risk elders from hospital through home to reduce readmissions and costs.

Question 4

Which document is considered the cornerstone of effective care transition communication between settings?

Accepted Answer

A comprehensive, timely discharge summary sent to the next provider

Answer

A timely, complete discharge summary with diagnosis, medications, pending results, and follow-up plan is the foundational communication tool for safe care transitions.

Question 5

A case manager is working with a patient who has limited English proficiency transitioning to home health care. Which action is MOST important?

Accepted Answer

Arranging for a trained medical interpreter for all transition-related communications

Answer

Federal law (Title VI of the Civil Rights Act) requires that healthcare organizations provide trained medical interpreters, not family members, for patients with limited English proficiency.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Care Transition Management 3