CCP CCP Transitional Care & Care Transitions 1

Question 1

The PRIMARY goal of transitional care management (TCM) for chronic disease patients is to:

Accepted Answer

Prevent hospital readmissions by ensuring continuity of care after discharge

Answer

TCM focuses on bridging care gaps immediately after hospital discharge to prevent avoidable readmissions and ensure patients remain stable in the community.

Question 2

Under CMS billing guidelines, a TCM 99496 code requires a face-to-face visit within how many days of discharge?

Accepted Answer

7 days

Answer

CPT 99496 requires a face-to-face visit within 7 days of discharge and is used for patients with high medical complexity.

Question 3

A CCP contacts a patient within 2 business days of hospital discharge. This contact is PRIMARILY intended to:

Accepted Answer

Assess the patient's condition, confirm follow-up, and address immediate post-discharge needs

Answer

The 2-business-day post-discharge contact is a TCM requirement to assess patient stability, confirm appointments, and address urgent needs before complications develop.

Question 4

Which intervention has the STRONGEST evidence for reducing 30-day readmissions in heart failure patients?

Accepted Answer

Early follow-up within 7 days combined with patient education on warning signs

Answer

Evidence consistently shows that early post-discharge follow-up combined with heart failure education on symptom monitoring significantly reduces 30-day readmission rates.

Question 5

The Coleman Care Transitions Intervention® focuses on developing which key patient skill?

Accepted Answer

Self-advocacy and self-management through the use of a personal health record

Answer

The Coleman model uses transition coaches and a Personal Health Record to build patients' self-advocacy skills across four care domains: medications, red flags, follow-up, and patient knowledge.

(CCP) Chronic Care Professional Certification Practice Test

(CCP) Chronic Care Professional Certification Practice Test

CCP CCP Transitional Care & Care Transitions 1