CCP Transitional Care & Care Transitions Flashcards
6 cards from real CCP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CCP Transitional Care & Care Transitions flashcards as text
The PRIMARY goal of transitional care management (TCM) for chronic disease patients is to:
Answer: Prevent hospital readmissions by ensuring continuity of care after discharge
TCM focuses on bridging care gaps immediately after hospital discharge to prevent avoidable readmissions and ensure patients remain stable in the community.
Under CMS billing guidelines, a TCM 99496 code requires a face-to-face visit within how many days of discharge?
Answer: 7 days
CPT 99496 requires a face-to-face visit within 7 days of discharge and is used for patients with high medical complexity.
A CCP contacts a patient within 2 business days of hospital discharge. This contact is PRIMARILY intended to:
Answer: Assess the patient's condition, confirm follow-up, and address immediate post-discharge needs
The 2-business-day post-discharge contact is a TCM requirement to assess patient stability, confirm appointments, and address urgent needs before complications develop.
Which intervention has the STRONGEST evidence for reducing 30-day readmissions in heart failure patients?
Answer: Early follow-up within 7 days combined with patient education on warning signs
Evidence consistently shows that early post-discharge follow-up combined with heart failure education on symptom monitoring significantly reduces 30-day readmission rates.
The Coleman Care Transitions Intervention® focuses on developing which key patient skill?
Answer: Self-advocacy and self-management through the use of a personal health record
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.
During a care transition, medication reconciliation is considered MOST critical because:
Answer: Discrepancies between inpatient and outpatient medication lists are a leading cause of adverse events
Medication discrepancies at discharge are one of the most common causes of preventable adverse drug events and hospital readmissions in the post-transition period.