CCM - Certified Case Manager Exam Certified Case Manager Care Transition Management 1 — Questions and Answers
Question 1: Which component of the Care Transitions Intervention (CTI) model is considered the cornerstone of empowering patients during the post-discharge period?
- Arranging transportation to follow-up appointments
- Using a personal health record maintained by the patient (Correct answer)
- Scheduling home health nursing visits within 24 hours
- Providing written medication lists to the discharging physician
Correct answer: Using a personal health record maintained by the patient
The CTI model developed by Eric Coleman centers on a patient-maintained personal health record (PHR) that the individual carries across all care settings, promoting self-management and continuity of information.
Question 2: A case manager is reconciling a patient's medications at discharge and discovers a discrepancy between the inpatient medication list and the patient's home regimen. What is the MOST appropriate immediate action?
- Discharge the patient and notify the outpatient pharmacist by fax
- Document the discrepancy in the chart and proceed with discharge
- Clarify the discrepancy with the prescribing physician before discharge is completed (Correct answer)
- Advise the patient to continue the home regimen and disregard the hospital changes
Correct answer: Clarify the discrepancy with the prescribing physician before discharge is completed
Medication discrepancies are a leading cause of adverse events after discharge. Resolving discrepancies with the prescribing physician prior to discharge prevents medication errors and reduces readmission risk.
Question 3: Under the Re-Engineered Discharge (RED) toolkit, which action is specifically required to close the communication loop between the hospital and the patient's primary care provider?
- Sending a discharge summary within 30 days of discharge
- Transmitting the discharge plan to the PCP before or on the day of discharge (Correct answer)
- Scheduling a telehealth visit with the PCP within two weeks
- Mailing a printed copy of the medication reconciliation form to the PCP
Correct answer: Transmitting the discharge plan to the PCP before or on the day of discharge
The RED toolkit requires that the primary care provider receive the discharge plan on or before the day of discharge so the outpatient team is prepared to continue care without gaps.
Question 4: A case manager is assessing a newly discharged patient for self-management ability. Which validated tool is MOST appropriate for evaluating a patient's activation level and readiness to manage their own health?
- The CAGE Questionnaire
- The Patient Activation Measure (PAM) (Correct answer)
- The Barthel Index
- The LACE Index
Correct answer: The Patient Activation Measure (PAM)
The Patient Activation Measure (PAM) quantifies a patient's knowledge, skills, and confidence in managing their health, making it the standard instrument for assessing self-management readiness during care transitions.
Question 5: Which of the following best describes the role of a Transition Coach in the Coleman Care Transitions Intervention?
- A licensed nurse who assumes clinical responsibility for the patient after discharge
- A trained professional who performs home assessments and orders follow-up labs
- A skilled facilitator who helps patients develop self-advocacy skills across care settings (Correct answer)
- A social worker who arranges community resources and housing supports
Correct answer: A skilled facilitator who helps patients develop self-advocacy skills across care settings
In the CTI model, the Transition Coach does not provide clinical care but instead works to build the patient's capacity to communicate with providers, manage medications, and recognize warning signs — empowering self-advocacy.
Question 6: When evaluating a care transition program's effectiveness, which outcome metric MOST directly reflects the program's impact on reducing preventable readmissions?
- Patient satisfaction scores at 30 days post-discharge
- The 30-day all-cause hospital readmission rate (Correct answer)
- Average length of stay for the index hospitalization
- The number of home health referrals generated at discharge
Correct answer: The 30-day all-cause hospital readmission rate
The 30-day all-cause readmission rate is the primary benchmark used by CMS and quality improvement frameworks to evaluate care transition effectiveness, as it captures preventable returns attributable to gaps in the transition process.
CCM - Certified Case Manager Exam Certified Case Manager Care Transition Management 1
Which component of the Care Transitions Intervention (CTI) model is considered the cornerstone of empowering patients during the post-discharge period?