CCP CCP Transitional Care & Care Transitions 3

Question 1

A CCP conducting a post-discharge phone call discovers that a patient did not fill their discharge prescriptions. The BEST response is to:

Accepted Answer

Explore the barrier (cost, access, understanding) and coordinate resolution immediately

Answer

Document it and wait for the next scheduled visit

Answer

Notify the discharging hospital and close the case

Answer

Refer the patient to an emergency department

Question 2

Which element is MOST important in a high-quality discharge summary for a patient with multiple chronic conditions?

Accepted Answer

Pending test results, follow-up instructions, reconciled medication list, and reason for hospitalization

Answer

A list of all physicians the patient has ever seen

Answer

Patient's insurance policy number and premium amount

Answer

Historical surgical records from more than 10 years ago

Question 3

Naylor's Transitional Care Model (TCM) is BEST characterized by:

Accepted Answer

Advanced practice nurse-led coordination across settings with a focus on high-risk patients

Answer

Physician-only management of post-discharge patients

Answer

Automated phone systems replacing human follow-up

Answer

Reducing all follow-up visits to a single 90-day check-in

Question 4

When a patient is discharged to home with new home health services, the CCP should coordinate with the home health agency to ensure:

Accepted Answer

Shared care goals, updated medication list, and clear communication channels are established

Answer

The agency manages all future specialist referrals independently

Answer

The patient's primary physician is removed from the care team

Answer

Home health nurses only perform administrative tasks

Question 5

Which of the following is a 'red flag' symptom that a CCP should instruct a patient with CHF to monitor daily after hospital discharge?

Accepted Answer

Weight gain of more than 2–3 pounds in a single day or 5 pounds in a week

Answer

Mild fatigue after moderate exercise

Answer

Occasional dry cough from ACE inhibitor use

Answer

Redness at the IV site that resolved before discharge

Question 6

A CCP is designing a care transition program for a high-risk patient panel. Which metric BEST evaluates the program's effectiveness?

Accepted Answer

30-day readmission rate and post-discharge follow-up visit completion rate

Answer

Total number of discharge summaries generated per month

Answer

Number of specialists consulted during hospitalization

Answer

Average inpatient length of stay before the program launched