CCM Care Transition Management 5 — Questions and Answers
Question 1: Which social determinant of health most frequently disrupts care transitions for low-income patients returning home from the hospital?
- Lack of transportation to follow-up appointments (Correct answer)
- Excess social support from extended family members
- Over-enrollment in community wellness programs
- High baseline health literacy scores
Correct answer: Lack of transportation to follow-up appointments
Transportation barriers are one of the most common social determinants that prevent low-income patients from attending post-discharge follow-up appointments and accessing medications.
Question 2: A case manager is reviewing a patient's transition to home after hip replacement surgery. Which finding would MOST concern the case manager regarding fall risk?
- The patient lives alone in a two-story home with the only bathroom upstairs (Correct answer)
- The patient has a daughter who calls twice a week to check in
- The patient's pain is well controlled with oral analgesics
- Physical therapy has been ordered for three times per week
Correct answer: The patient lives alone in a two-story home with the only bathroom upstairs
A post-surgical patient living alone with required stair-climbing to access the bathroom faces a high fall risk that must be addressed before or immediately after discharge.
Question 3: When a case manager identifies that a patient's post-discharge medications are not covered by their insurance plan, the FIRST step is to:
- Contact the prescribing physician to request a formulary-covered therapeutic alternative (Correct answer)
- Advise the patient to stop taking the medication until coverage is resolved
- File a grievance with the state insurance commissioner
- Ask the patient to purchase the medication out-of-pocket immediately
Correct answer: Contact the prescribing physician to request a formulary-covered therapeutic alternative
Working with the physician to substitute a covered alternative is the fastest, safest solution—ensuring the patient receives needed therapy without delay or financial hardship.
Question 4: The RED (Re-Engineered Discharge) program is an evidence-based transition intervention that MOST emphasizes:
- A structured nurse-led discharge process with 11 mutually reinforcing components (Correct answer)
- Physician-to-physician phone calls at the time of discharge only
- Remote patient monitoring technology as the primary transition tool
- Group patient education classes before hospital discharge
Correct answer: A structured nurse-led discharge process with 11 mutually reinforcing components
Project RED (Boston University/BMC) uses a nurse 'discharge advocate' who applies 11 standardized components including written care plans, medication review, and a post-discharge phone call to reduce readmissions.
Question 5: A case manager is assessing a patient's caregiver for ability to manage care at home after discharge. Which caregiver factor would MOST increase the patient's risk of readmission?
- The caregiver expresses feeling overwhelmed and has no backup support (Correct answer)
- The caregiver completed a 4-hour family education class during the hospitalization
- The caregiver has cared for another family member with a similar diagnosis
- The caregiver lives in the same home as the patient
Correct answer: The caregiver expresses feeling overwhelmed and has no backup support
Caregiver burnout and lack of backup support directly compromise the quality of home care, increasing the likelihood of unmanaged complications and emergency readmission.
Question 6: Which approach BEST supports continuity of care when a patient transitions from a hospitalist's care back to a primary care physician (PCP)?
- Sending a complete discharge summary to the PCP before the follow-up appointment and confirming the appointment was scheduled (Correct answer)
- Having the patient verbally inform the PCP of what happened during hospitalization
- Transferring the entire inpatient medical record to the PCP via postal mail
- Allowing the PCP to request records only if the patient returns with complications
Correct answer: Sending a complete discharge summary to the PCP before the follow-up appointment and confirming the appointment was scheduled
Proactive transmission of the discharge summary combined with a confirmed follow-up appointment closes the most common communication gaps between hospital and outpatient care.
Question 7: A case manager is preparing a transition plan for a patient with advanced heart failure who has expressed a wish to avoid future hospitalizations. The MOST appropriate next step is to:
- Initiate a goals-of-care conversation and consider a palliative care referral aligned with the patient's wishes (Correct answer)
- Increase the frequency of specialty cardiology outpatient appointments
- Refer the patient to cardiac rehabilitation for intensive exercise therapy
- Arrange for an implantable cardiac defibrillator evaluation
Correct answer: Initiate a goals-of-care conversation and consider a palliative care referral aligned with the patient's wishes
When a patient with serious illness expresses a preference to avoid hospitalization, goals-of-care discussion and palliative care referral align the care plan with the patient's values and can improve quality of life.
CCM Care Transition Management 5
Which social determinant of health most frequently disrupts care transitions for low-income patients returning home from the hospital?