CCM Care Transition Management 5

Question 1

Which social determinant of health most frequently disrupts care transitions for low-income patients returning home from the hospital?

Accepted Answer

Lack of transportation to follow-up appointments

Answer

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?

Accepted Answer

The patient lives alone in a two-story home with the only bathroom upstairs

Answer

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:

Accepted Answer

Contact the prescribing physician to request a formulary-covered therapeutic alternative

Answer

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:

Accepted Answer

A structured nurse-led discharge process with 11 mutually reinforcing components

Answer

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?

Accepted Answer

The caregiver expresses feeling overwhelmed and has no backup support

Answer

Caregiver burnout and lack of backup support directly compromise the quality of home care, increasing the likelihood of unmanaged complications and emergency readmission.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Care Transition Management 5