CCMC - Commission for Case Manager Care Coordination and Transitions Questions and Answers

Question 1

An elderly client with multiple comorbidities, including diabetes, heart failure, and early-stage dementia, is being discharged from the hospital to home.
The client's primary caregiver is their spouse, who is also elderly and appears overwhelmed.
Which of the following is the case manager's HIGHEST priority intervention to ensure a safe transition of care?

Accepted Answer

Conducting a comprehensive caregiver assessment and providing education on medication management and warning signs.

Answer

Scheduling a follow-up appointment with the primary care physician within 7 days.

Answer

Arranging for the delivery of all necessary durable medical equipment.

Answer

Providing a list of community support groups for dementia caregivers.

Question 2

The Transitional Care Model (TCM), an evidence-based approach to improve outcomes for high-risk older adults, is distinguished by its reliance on which key element?

Accepted Answer

An advanced practice nurse (APN) who engages with the client from the hospital to the home, including in-person follow-up visits.

Answer

A hospital-based discharge planner who coordinates all post-discharge services via telephone.

Answer

A primary care physician who leads a multidisciplinary team meeting for every patient prior to discharge.

Answer

A pharmacist-led medication reconciliation program at the time of discharge and a 7-day follow-up call.

Question 3

Which of the following is the MOST comprehensive description of medication reconciliation during a transition of care?

Accepted Answer

Comparing the client's pre-hospitalization medication list with the medications prescribed at discharge to identify and resolve any discrepancies.

Answer

Providing the client with a printed list of their new prescriptions before they leave the facility.

Answer

Educating the client on the purpose and potential side effects of each new medication prescribed.

Answer

Calling the client's pharmacy to confirm that all new prescriptions have been successfully transmitted and filled.

Question 4

A case manager makes a follow-up call two days after a 72-year-old client was discharged home after a hospitalization for pneumonia. The client reveals they have not filled their new antibiotic prescription because they 'didn't have a ride' and felt 'too weak to go out.' What is the case manager's IMMEDIATE next step?

Accepted Answer

Arrange for immediate delivery of the medication from a local pharmacy that offers this service.

Answer

Educate the client on the importance of taking the antibiotic to prevent a relapse.

Answer

Document the client's non-adherence and the stated barriers in the chart.

Answer

Schedule a home health aide to visit the client the following day to assist with errands.

Question 5

A hospital case manager uses a standardized form to communicate a client's clinical status, active medical issues, medication list, and follow-up needs directly to the intake nurse at the receiving skilled nursing facility via a secure portal. This structured transfer of information is a key component of a:

Accepted Answer

Warm handoff.

Answer

Root cause analysis.

Answer

Patient activation measure.

Answer

Sentinel event review.

Question 6

Which of the following represents a significant system-level barrier to effective care transitions, as opposed to a patient-specific factor?

Accepted Answer

The discharging hospital's electronic health record (EHR) is not interoperable with the receiving home health agency's EHR.

Answer

The client has low health literacy and does not understand their discharge instructions.

Answer

The client lacks family support to assist with care and transportation at home.

Answer

The client is financially unable to afford the co-pays for their new medications.