CCM - Certified Case Manager Exam Certified Case Manager Care Transition Management 1

Question 1

Which component of the Care Transitions Intervention (CTI) model is considered the cornerstone of empowering patients during the post-discharge period?

Accepted Answer

Using a personal health record maintained by the patient

Answer

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?

Accepted Answer

Clarify the discrepancy with the prescribing physician before discharge is completed

Answer

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?

Accepted Answer

Transmitting the discharge plan to the PCP before or on the day of discharge

Answer

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?

Accepted Answer

The Patient Activation Measure (PAM)

Answer

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?

Accepted Answer

A skilled facilitator who helps patients develop self-advocacy skills across care settings

Answer

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.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Certified Case Manager Care Transition Management 1