CCP Chronic Disease Management & Care Coordination 2 — Questions and Answers
Question 1: 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?
- Scheduling more frequent physician office visits
- Implementing a structured post-discharge follow-up call within 48–72 hours (Correct answer)
- Increasing diuretic dosage without physician review
- Referring the patient to a cardiologist for the first time
Correct 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.
Question 2: The Chronic Care Model (CCM) identifies which of the following as a core component that supports informed, activated patients?
- Fee-for-service reimbursement structures
- Self-management support (Correct answer)
- Reactive acute care delivery
- Specialist-only care teams
Correct 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.
Question 3: When developing a care plan for a patient with multiple chronic conditions, which approach is considered BEST practice?
- Treating each condition independently with separate specialists
- Creating a unified, patient-centered care plan that addresses all conditions holistically (Correct answer)
- Prioritizing the most recent diagnosis over longstanding conditions
- Deferring care planning until the patient requests it
Correct 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.
Question 4: Which metric is MOST appropriate for evaluating the effectiveness of a diabetes chronic care management program?
- Number of specialist referrals generated
- Percentage of patients achieving HbA1c targets (Correct answer)
- Total number of patient phone calls logged
- Frequency of office visit scheduling
Correct answer: Percentage of patients achieving HbA1c targets
HbA1c target achievement is the primary clinical outcome measure used to evaluate diabetes management program effectiveness.
Question 5: 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:
- Wait for the patient's next appointment to mention the concern
- Alert the prescribing providers immediately and document the finding (Correct answer)
- Instruct the patient to stop all medications until resolved
- Report the interaction only to the pharmacy
Correct 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.
Question 6: Health literacy screening is important in chronic care management primarily because:
- It satisfies Joint Commission accreditation requirements
- Low health literacy is associated with worse chronic disease self-management and outcomes (Correct answer)
- It reduces the need for patient education materials
- High health literacy patients require more care coordination
Correct 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.
Question 7: Which of the following BEST describes the role of a community health worker (CHW) in chronic care management?
- Diagnosing and treating chronic conditions independently
- Bridging the gap between clinical care and community resources for underserved patients (Correct answer)
- Replacing care coordinators in high-volume practices
- Authorizing specialist referrals on behalf of physicians
Correct 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.
CCP Chronic Disease Management & Care Coordination 2
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?