2026 CCCTM Exam Prep: Care Coordination &
Transition Management Practice Questions,
Answer Rationales, Patient Navigation,
Collaboration, Outcomes, Discharge Planning &
Clinical Management Study Guide
SECTION 1: CARE COORDINATION & TRANSITION MANAGEMENT
Q1. A care coordinator is using the LACE Index to assess readmission risk. Which
factors are included?
A. Length of stay, acuity, comorbidity, emergency department visits
B. Living situation, age, chronic illness, education
C. Lab values, activity level, cognition, environment
D. Language, access, compliance, education
Answer: A
Rationale: LACE = Length of stay, Acuity of admission, Comorbidity, Emergency
department visits in the past 6 months. It predicts 30-day readmission risk. B, C,
and D are not components of LACE.
Q2. During a transition from hospital to skilled nursing facility, the care
coordinator's primary responsibility is to:
A. Complete all discharge paperwork for the physician
B. Ensure seamless communication of the patient's plan of care across settings
C. Authorize insurance coverage for the SNF stay
D. Provide direct bedside nursing care during transport
Answer: B
Rationale: The core of transition management is communication and
coordination across settings to prevent gaps in care. Insurance authorization and
direct care are outside the care coordinator's scope.
,Q3. Which patient is at highest risk for a poor transition?
A. A 45-year-old with a stable fracture, discharged home with family support
B. A 72-year-old with heart failure, lives alone, on 12 medications, no
transportation
C. A 30-year-old with asthma, has a primary care appointment in 2 weeks
D. A 60-year-old with hypertension, married, retired, active in community
Answer: B
Rationale: Multiple risk factors: older age, chronic illness, polypharmacy, social
isolation, lack of transportation. These are classic SDOH and clinical risk factors for
readmission.
Q4. The Transitional Care Model (TCM) is best described as:
A. A physician-led model focused on acute care
B. A nurse-led model focusing on older adults with chronic illness transitioning
from hospital to home
C. A pharmacist-led model for medication reconciliation only
D. A social worker-led model for housing placement
Answer: B
Rationale: The TCM is nurse-led, targets older adults with chronic illness, and
emphasizes transitional care from hospital to home. It is not physician,
pharmacist, or social worker-led.
Q5. The Care Transitions Intervention (CTI) by Coleman includes which four
pillars?
A. Medication self-management, patient-centered record, follow-up, red flags
B. Housing, food, transportation, income
C. Assessment, diagnosis, treatment, evaluation
D. Admission, discharge, transfer, follow-up
,Answer: A
Rationale: The CTI's four pillars are medication self-management, a patient-
centered record, follow-up, and red flags. B refers to SDOH, C is the nursing
process, and D is a generic flow.
Q6. AHRQ IDEAL Discharge Planning stands for:
A. Include, Discuss, Educate, Assess, Listen
B. Identify, Diagnose, Evaluate, Act, Learn
C. Inform, Document, Explain, Advise, Link
D. Interview, Decide, Educate, Assess, Log
Answer: A
Rationale: IDEAL = Include, Discuss, Educate, Assess, Listen. It is an AHRQ
framework for engaging patients and families in discharge planning.
Q7. Which of the following is a social determinant of health (SDOH)?
A. Blood pressure reading
B. Housing instability
C. HbA1c level
D. Genetic predisposition
Answer: B
Rationale: SDOH include housing, food security, transportation, income,
education, and social support. Blood pressure and HbA1c are clinical measures;
genetics is biological.
Q8. A care coordinator is stratifying a patient panel. Which tool is commonly used
for risk stratification?
A. Glasgow Coma Scale
B. LACE Index
C. APGAR Score
D. Braden Scale
, Answer: B
Rationale: The LACE Index stratifies readmission risk. Glasgow Coma Scale
assesses consciousness, APGAR assesses newborns, and Braden assesses pressure
ulcer risk.
Q9. Which intervention best prevents gaps in care during a transition from ED to
home?
A. Sending the patient home with verbal instructions only
B. Providing a written discharge summary and scheduling follow-up before
departure
C. Asking the patient to call if they have questions
D. Mailing instructions one week later
Answer: B
Rationale: Written discharge summaries and scheduled follow-up before
departure prevent gaps. Verbal-only, passive, or delayed instructions increase
risk.
Q10. A patient is transitioning from hospital to home hospice. The care
coordinator's priority is to:
A. Ensure comfort, symptom management, and family support are in place
B. Schedule aggressive curative treatment
C. Arrange for daily lab draws
D. Refer to physical therapy for strengthening
Answer: A
Rationale: Hospice focuses on comfort and quality of life. Curative treatment,
daily labs, and strengthening are not aligned with hospice goals.
Q11. Which model emphasizes self-management support, decision support, and
clinical information systems?
Transition Management Practice Questions,
Answer Rationales, Patient Navigation,
Collaboration, Outcomes, Discharge Planning &
Clinical Management Study Guide
SECTION 1: CARE COORDINATION & TRANSITION MANAGEMENT
Q1. A care coordinator is using the LACE Index to assess readmission risk. Which
factors are included?
A. Length of stay, acuity, comorbidity, emergency department visits
B. Living situation, age, chronic illness, education
C. Lab values, activity level, cognition, environment
D. Language, access, compliance, education
Answer: A
Rationale: LACE = Length of stay, Acuity of admission, Comorbidity, Emergency
department visits in the past 6 months. It predicts 30-day readmission risk. B, C,
and D are not components of LACE.
Q2. During a transition from hospital to skilled nursing facility, the care
coordinator's primary responsibility is to:
A. Complete all discharge paperwork for the physician
B. Ensure seamless communication of the patient's plan of care across settings
C. Authorize insurance coverage for the SNF stay
D. Provide direct bedside nursing care during transport
Answer: B
Rationale: The core of transition management is communication and
coordination across settings to prevent gaps in care. Insurance authorization and
direct care are outside the care coordinator's scope.
,Q3. Which patient is at highest risk for a poor transition?
A. A 45-year-old with a stable fracture, discharged home with family support
B. A 72-year-old with heart failure, lives alone, on 12 medications, no
transportation
C. A 30-year-old with asthma, has a primary care appointment in 2 weeks
D. A 60-year-old with hypertension, married, retired, active in community
Answer: B
Rationale: Multiple risk factors: older age, chronic illness, polypharmacy, social
isolation, lack of transportation. These are classic SDOH and clinical risk factors for
readmission.
Q4. The Transitional Care Model (TCM) is best described as:
A. A physician-led model focused on acute care
B. A nurse-led model focusing on older adults with chronic illness transitioning
from hospital to home
C. A pharmacist-led model for medication reconciliation only
D. A social worker-led model for housing placement
Answer: B
Rationale: The TCM is nurse-led, targets older adults with chronic illness, and
emphasizes transitional care from hospital to home. It is not physician,
pharmacist, or social worker-led.
Q5. The Care Transitions Intervention (CTI) by Coleman includes which four
pillars?
A. Medication self-management, patient-centered record, follow-up, red flags
B. Housing, food, transportation, income
C. Assessment, diagnosis, treatment, evaluation
D. Admission, discharge, transfer, follow-up
,Answer: A
Rationale: The CTI's four pillars are medication self-management, a patient-
centered record, follow-up, and red flags. B refers to SDOH, C is the nursing
process, and D is a generic flow.
Q6. AHRQ IDEAL Discharge Planning stands for:
A. Include, Discuss, Educate, Assess, Listen
B. Identify, Diagnose, Evaluate, Act, Learn
C. Inform, Document, Explain, Advise, Link
D. Interview, Decide, Educate, Assess, Log
Answer: A
Rationale: IDEAL = Include, Discuss, Educate, Assess, Listen. It is an AHRQ
framework for engaging patients and families in discharge planning.
Q7. Which of the following is a social determinant of health (SDOH)?
A. Blood pressure reading
B. Housing instability
C. HbA1c level
D. Genetic predisposition
Answer: B
Rationale: SDOH include housing, food security, transportation, income,
education, and social support. Blood pressure and HbA1c are clinical measures;
genetics is biological.
Q8. A care coordinator is stratifying a patient panel. Which tool is commonly used
for risk stratification?
A. Glasgow Coma Scale
B. LACE Index
C. APGAR Score
D. Braden Scale
, Answer: B
Rationale: The LACE Index stratifies readmission risk. Glasgow Coma Scale
assesses consciousness, APGAR assesses newborns, and Braden assesses pressure
ulcer risk.
Q9. Which intervention best prevents gaps in care during a transition from ED to
home?
A. Sending the patient home with verbal instructions only
B. Providing a written discharge summary and scheduling follow-up before
departure
C. Asking the patient to call if they have questions
D. Mailing instructions one week later
Answer: B
Rationale: Written discharge summaries and scheduled follow-up before
departure prevent gaps. Verbal-only, passive, or delayed instructions increase
risk.
Q10. A patient is transitioning from hospital to home hospice. The care
coordinator's priority is to:
A. Ensure comfort, symptom management, and family support are in place
B. Schedule aggressive curative treatment
C. Arrange for daily lab draws
D. Refer to physical therapy for strengthening
Answer: A
Rationale: Hospice focuses on comfort and quality of life. Curative treatment,
daily labs, and strengthening are not aligned with hospice goals.
Q11. Which model emphasizes self-management support, decision support, and
clinical information systems?
