CCP Interdisciplinary Team Roles 3 — Questions and Answers
Question 1: A behavioral health specialist embedded in a chronic care team is MOST focused on:
- Reviewing laboratory panels
- Addressing depression, anxiety, and health behavior change (Correct answer)
- Managing prescription renewals
- Conducting physical examinations
Correct answer: Addressing depression, anxiety, and health behavior change
Behavioral health specialists address mental health comorbidities and motivate behavior change, which are critical drivers of chronic disease outcomes.
Question 2: During a team huddle, the nurse practitioner reports a patient's HbA1c remains uncontrolled at 9.8%. Which team action reflects TRUE interdisciplinary practice?
- The physician alone adjusts medications
- The team jointly reviews adherence, diet, stress, and medications before developing a plan (Correct answer)
- The pharmacist independently changes the regimen
- The issue is tabled until the next quarterly meeting
Correct answer: The team jointly reviews adherence, diet, stress, and medications before developing a plan
True interdisciplinary practice involves all relevant disciplines contributing their expertise simultaneously to form a unified, patient-centered plan.
Question 3: A health educator on the chronic care team is developing a self-management program for patients with heart failure. The educator's PRIMARY goal is to:
- Prescribe diuretic medications
- Build patients' knowledge and skills to recognize and respond to symptom changes (Correct answer)
- Order daily weight monitoring labs
- Coordinate with insurance for prior authorizations
Correct answer: Build patients' knowledge and skills to recognize and respond to symptom changes
Health educators empower patients with the knowledge and self-efficacy to monitor symptoms and take appropriate action, reducing hospitalizations.
Question 4: A case manager's role in chronic care is BEST described as:
- Providing direct clinical therapy
- Coordinating services across providers and settings to meet patient goals (Correct answer)
- Prescribing specialty medications
- Performing surgical follow-up
Correct answer: Coordinating services across providers and settings to meet patient goals
Case managers serve as central coordinators who align clinical services, community resources, and patient goals across the continuum of care.
Question 5: Which team member is PRIMARILY responsible for assessing a patient's functional ability to perform activities of daily living (ADLs) in the home setting?
- Pharmacist
- Occupational therapist (Correct answer)
- Social worker
- Registered dietitian
Correct answer: Occupational therapist
Occupational therapists evaluate and retrain patients in ADLs, adapting tasks and environments to support independent functioning at home.
Question 6: In the chronic care model, which team role is specifically tasked with ensuring the patient's voice and preferences are represented in care planning?
- Medical billing specialist
- Patient advocate or care navigator (Correct answer)
- Laboratory technician
- Insurance case reviewer
Correct answer: Patient advocate or care navigator
Patient advocates and care navigators ensure that the patient's values, preferences, and cultural needs guide all care decisions made by the team.
Question 7: An interdisciplinary team is caring for a patient with end-stage renal disease who refuses dialysis. The APPROPRIATE team response is to:
- Override the refusal and initiate dialysis
- Involve palliative care and social work to support the patient's informed decision-making (Correct answer)
- Discharge the patient immediately
- Refer only to nephrology to persuade the patient
Correct answer: Involve palliative care and social work to support the patient's informed decision-making
Palliative care and social work collaborate with the team to ensure the patient has full information, support, and comfort-focused alternatives respecting autonomy.
CCP Interdisciplinary Team Roles 3
A behavioral health specialist embedded in a chronic care team is MOST focused on: