CCP CCP Transitional Care & Care Transitions 2 — Questions and Answers
Question 1: A CCP is using the BOOST toolkit. This resource is designed to help healthcare teams:
- Conduct Semrush keyword research for patient portals
- Improve discharge planning and reduce readmissions through structured processes (Correct answer)
- Train patients in physical therapy techniques
- Manage chronic pain through pharmacological protocols
Correct answer: Improve discharge planning and reduce readmissions through structured processes
BOOST (Better Outcomes for Older Adults through Safe Transitions) provides hospitals and care teams with tools and best practices to optimize discharge planning and reduce readmissions.
Question 2: Which patient population is at HIGHEST risk for poor outcomes during care transitions?
- Young adults with a single acute illness
- Elderly patients with multiple chronic conditions and limited social support (Correct answer)
- Patients with employer-sponsored insurance only
- Patients who completed a rehabilitation program
Correct answer: Elderly patients with multiple chronic conditions and limited social support
Elderly patients with multiple comorbidities and limited social support face the greatest risk of adverse events, readmissions, and functional decline during care transitions.
Question 3: The LACE index is used in transitional care to predict:
- A patient's likelihood of medication side effects
- Risk of 30-day readmission or death after hospital discharge (Correct answer)
- Appropriate dosing for anticoagulant therapy
- Suitability for chronic care management billing
Correct answer: Risk of 30-day readmission or death after hospital discharge
The LACE index scores patients on Length of stay, Acuity of admission, Comorbidity, and Emergency department visits to estimate 30-day readmission or mortality risk.
Question 4: A 'teach-back' method used during care transitions verifies that:
- The patient has signed all discharge paperwork
- The patient can correctly explain discharge instructions in their own words (Correct answer)
- Insurance has pre-authorized follow-up visits
- The electronic health record has been updated
Correct answer: The patient can correctly explain discharge instructions in their own words
Teach-back is an evidence-based technique where the patient repeats instructions in their own words, confirming comprehension and identifying gaps before discharge.
Question 5: A patient is transitioning from hospital to a skilled nursing facility (SNF). The CCP's PRIORITY action is to:
- Wait until the patient returns home before initiating any contact
- Ensure an accurate discharge summary with medication list is sent to the SNF before or at transfer (Correct answer)
- Cancel all outpatient follow-up appointments
- Discontinue chronic care management during the SNF stay
Correct answer: Ensure an accurate discharge summary with medication list is sent to the SNF before or at transfer
Timely transmission of an accurate discharge summary including the complete medication list is critical to safe handoffs between care settings and prevents errors at the SNF.
Question 6: Under the Hospital Readmissions Reduction Program (HRRP), hospitals face financial penalties for excess readmissions in which conditions?
- Asthma, migraines, and obesity
- Heart failure, pneumonia, COPD, hip/knee arthroplasty, CABG, and AMI (Correct answer)
- Cancer, dementia, and diabetes
- Renal failure, stroke, and hepatitis
Correct answer: Heart failure, pneumonia, COPD, hip/knee arthroplasty, CABG, and AMI
HRRP penalizes hospitals for higher-than-expected 30-day readmission rates for six conditions: AMI, heart failure, pneumonia, COPD, hip/knee arthroplasty, and CABG.
CCP CCP Transitional Care & Care Transitions 2
A CCP is using the BOOST toolkit.
This resource is designed to help healthcare teams: