Chronic Disease Management & Care Coordination Flashcards
7 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 7 Chronic Disease Management & Care Coordination flashcards as text
A care coordinator notices a patient with heart failure has been hospitalized three times in six months. Which intervention is MOST likely to reduce readmissions?
Answer: Implementing a structured post-discharge follow-up call within 48–72 hours
Post-discharge follow-up calls within 48–72 hours are evidence-based interventions proven to reduce heart failure readmissions by catching early warning signs.
The Chronic Care Model (CCM) identifies which of the following as a core component that supports informed, activated patients?
Answer: Self-management support
Self-management support is one of the six core elements of the Chronic Care Model, empowering patients to actively participate in managing their own conditions.
When developing a care plan for a patient with multiple chronic conditions, which approach is considered BEST practice?
Answer: Creating a unified, patient-centered care plan that addresses all conditions holistically
A unified, patient-centered care plan that addresses comorbidities holistically prevents fragmented care and reduces the risk of conflicting treatments.
Which metric is MOST appropriate for evaluating the effectiveness of a diabetes chronic care management program?
Answer: Percentage of patients achieving HbA1c targets
HbA1c target achievement is the primary clinical outcome measure used to evaluate diabetes management program effectiveness.
A care team member identifies that a patient's medications from three different prescribers contain a dangerous drug-drug interaction. The FIRST step should be to:
Answer: Alert the prescribing providers immediately and document the finding
Alerting all prescribing providers immediately ensures patient safety and facilitates prompt medication reconciliation across the care team.
Health literacy screening is important in chronic care management primarily because:
Answer: Low health literacy is associated with worse chronic disease self-management and outcomes
Low health literacy is strongly linked to poor medication adherence, worse disease self-management, and higher hospitalization rates in chronic disease populations.
Which of the following BEST describes the role of a community health worker (CHW) in chronic care management?
Answer: Bridging the gap between clinical care and community resources for underserved patients
Community health workers serve as cultural liaisons who connect patients—especially in underserved populations—to community resources, improving care access and adherence.