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 patient with COPD reports using their rescue inhaler more than twice per week. According to GINA/GOLD guidelines, this finding indicates:
Answer: Poorly controlled disease requiring step-up therapy review
Rescue inhaler use more than twice per week is a recognized marker of poorly controlled COPD/asthma that triggers a therapy reassessment per GOLD guidelines.
Which population health tool BEST helps care coordinators identify high-risk patients who may need proactive outreach?
Answer: Risk stratification algorithms using claims and clinical data
Risk stratification algorithms analyze claims, clinical, and social determinants data to identify high-risk patients before crisis events occur.
When a care coordinator facilitates a transition from hospital to skilled nursing facility (SNF), which document is MOST critical to send at the time of transfer?
Answer: Comprehensive medication reconciliation list
A comprehensive, reconciled medication list at transfer prevents medication errors, which are the leading cause of adverse events during care transitions.
The PDSA cycle used in chronic care quality improvement stands for:
Answer: Plan, Do, Study, Act
The Plan-Do-Study-Act (PDSA) cycle is the standard rapid-cycle improvement methodology used in healthcare quality improvement initiatives.
A patient with type 2 diabetes also has stage 3 chronic kidney disease (CKD). Which medication commonly used in diabetes management requires dose adjustment or avoidance in this patient?
Answer: Metformin
Metformin is contraindicated or requires dose reduction in CKD stage 3b and beyond due to risk of lactic acidosis from impaired renal clearance.
Social determinants of health (SDOH) screening in chronic disease management is MOST important because:
Answer: Unmet social needs like food insecurity and housing instability directly worsen chronic disease outcomes
Research consistently shows that SDOH such as food insecurity, housing instability, and transportation barriers are major drivers of poor chronic disease outcomes and health disparities.
In a patient-centered medical home (PCMH), care coordination responsibilities are PRIMARILY held by:
Answer: The entire care team, including non-physician team members
PCMH models distribute care coordination responsibility across the entire interdisciplinary team, not solely to physicians or external case managers.