CCP CCP Transitional Care & Care Transitions 3

Question 1

A CCP conducting a post-discharge phone call discovers that a patient did not fill their discharge prescriptions. The BEST response is to:

Accepted Answer

Explore the barrier (cost, access, understanding) and coordinate resolution immediately

Answer

Identifying and resolving medication barriers immediately after discharge is critical to preventing adverse events and readmissions from gaps in therapy.

Question 2

Which element is MOST important in a high-quality discharge summary for a patient with multiple chronic conditions?

Accepted Answer

Pending test results, follow-up instructions, reconciled medication list, and reason for hospitalization

Answer

High-quality discharge summaries must include the reconciled medication list, reason for admission, pending results, and clear follow-up instructions to ensure care continuity.

Question 3

Naylor's Transitional Care Model (TCM) is BEST characterized by:

Accepted Answer

Advanced practice nurse-led coordination across settings with a focus on high-risk patients

Answer

Naylor's TCM uses advanced practice registered nurses to provide comprehensive, patient-centered transitional care across hospital, home, and outpatient settings for high-risk chronic patients.

Question 4

When a patient is discharged to home with new home health services, the CCP should coordinate with the home health agency to ensure:

Accepted Answer

Shared care goals, updated medication list, and clear communication channels are established

Answer

Effective coordination with home health agencies requires sharing aligned care goals, an updated medication list, and establishing clear communication protocols to prevent fragmented care.

Question 5

Which of the following is a 'red flag' symptom that a CCP should instruct a patient with CHF to monitor daily after hospital discharge?

Accepted Answer

Weight gain of more than 2–3 pounds in a single day or 5 pounds in a week

Answer

Rapid weight gain indicates fluid retention in CHF patients and is an early warning sign of decompensation that requires immediate clinical evaluation.

(CCP) Chronic Care Professional Certification Practice Test

(CCP) Chronic Care Professional Certification Practice Test

CCP CCP Transitional Care & Care Transitions 3