CCCTM 2026 Study Guide: Care Coordination and
Transition Management Certification Practice
Questions Answer Explanations & Patient
Navigation, Collaboration, Outcomes & Healthcare
Transitions Exam Preparation
DOMAIN 1: PATIENT NAVIGATION
Question 1
A care coordination nurse is helping a patient with newly diagnosed diabetes. The
patient lives in a food desert and has limited transportation. Which action should
the nurse take first?
A. Provide a list of endocrinologists in the area.
B. Assess the patient's specific barriers to self-management.
C. Schedule a follow-up appointment in 3 months.
D. Teach the patient about carbohydrate counting.
Correct Answer: B
Rationale: The nurse should first assess the patient's barriers (SDOH) before
implementing interventions. Understanding food access and transportation issues
allows for tailored navigation. A, C, and D are appropriate but not the first step.
Question 2
Which factor is most likely to impede a patient's ability to navigate the healthcare
system?
A. Strong family support.
B. Health literacy level.
C. Access to a primary care provider.
D. Insurance coverage.
,Correct Answer: B
Rationale: Low health literacy affects understanding of instructions, medications,
and appointments, making navigation difficult. A, C, and D are facilitators, not
barriers.
Question 3
A patient who speaks limited English is being discharged. Which resource should
the care coordination nurse prioritize?
A. A written discharge summary in English.
B. A qualified medical interpreter for discharge teaching.
C. A pamphlet with pictures only.
D. Instructions to have a family member translate.
Correct Answer: B
Rationale: Using a qualified medical interpreter ensures accurate understanding
of discharge instructions. A is insufficient; C may lack detail; D risks
miscommunication and violates best practices.
Question 4
Which social determinant of health has the greatest impact on a patient's ability
to attend follow-up appointments?
A. Race and ethnicity.
B. Transportation availability.
C. Marital status.
D. Educational level.
Correct Answer: B
Rationale: Lack of transportation is a direct, practical barrier to attending
appointments. While A, C, and D influence health, transportation is most
immediately linked to appointment attendance.
,Question 5
A care coordination nurse is assessing a patient's health literacy. Which question
is most appropriate?
A. "Can you read and write?"
B. "How confident are you filling out medical forms by yourself?"
C. "What is your highest level of education?"
D. "Do you understand English?"
Correct Answer: B
Rationale: The "Single Item Literacy Screener" or confidence-based questions
assess health literacy without shame. A, C, and D do not accurately measure
functional health literacy.
Question 6
A patient is uninsured and needs expensive medications. What is the best
navigation action?
A. Tell the patient to apply for Medicaid.
B. Refer the patient to a social worker for medication assistance programs.
C. Advise the patient to skip doses to save money.
D. Recommend over-the-counter alternatives.
Correct Answer: B
Rationale: Social workers can connect patients to pharmaceutical assistance
programs, patient assistance foundations, and discount programs. A may not be
feasible; C is dangerous; D may be inappropriate.
Question 7
Which action best demonstrates patient advocacy in care coordination?
A. Making decisions for the patient.
B. Ensuring the patient's preferences are included in the care plan.
C. Avoiding discussion of sensitive topics.
D. Limiting family involvement.
, Correct Answer: B
Rationale: Advocacy means ensuring patient preferences and values guide care. A
is paternalistic; C avoids necessary communication; D may exclude important
support.
Question 8
A patient with limited income is prescribed a costly inhaler. Which resource
should the nurse explore first?
A. Emergency department voucher programs.
B. Pharmaceutical manufacturer patient assistance programs.
C. Hospital charity care.
D. Crowdfunding websites.
Correct Answer: B
Rationale: Manufacturer assistance programs often provide free or reduced-cost
medications. A, C, and D are less reliable and not first-line navigation strategies.
Question 9
A care coordination nurse is helping a homeless patient manage hypertension.
Which intervention is most important?
A. Providing a 90-day supply of medication.
B. Connecting the patient with a shelter and food resources.
C. Scheduling weekly clinic visits.
D. Teaching a low-sodium diet.
Correct Answer: B
Rationale: Maslow's hierarchy—basic needs (shelter, food) must be addressed
before chronic disease management. A, C, and D are important but secondary.
Question 10
Which tool is best for identifying patients who need care coordination services?
Transition Management Certification Practice
Questions Answer Explanations & Patient
Navigation, Collaboration, Outcomes & Healthcare
Transitions Exam Preparation
DOMAIN 1: PATIENT NAVIGATION
Question 1
A care coordination nurse is helping a patient with newly diagnosed diabetes. The
patient lives in a food desert and has limited transportation. Which action should
the nurse take first?
A. Provide a list of endocrinologists in the area.
B. Assess the patient's specific barriers to self-management.
C. Schedule a follow-up appointment in 3 months.
D. Teach the patient about carbohydrate counting.
Correct Answer: B
Rationale: The nurse should first assess the patient's barriers (SDOH) before
implementing interventions. Understanding food access and transportation issues
allows for tailored navigation. A, C, and D are appropriate but not the first step.
Question 2
Which factor is most likely to impede a patient's ability to navigate the healthcare
system?
A. Strong family support.
B. Health literacy level.
C. Access to a primary care provider.
D. Insurance coverage.
,Correct Answer: B
Rationale: Low health literacy affects understanding of instructions, medications,
and appointments, making navigation difficult. A, C, and D are facilitators, not
barriers.
Question 3
A patient who speaks limited English is being discharged. Which resource should
the care coordination nurse prioritize?
A. A written discharge summary in English.
B. A qualified medical interpreter for discharge teaching.
C. A pamphlet with pictures only.
D. Instructions to have a family member translate.
Correct Answer: B
Rationale: Using a qualified medical interpreter ensures accurate understanding
of discharge instructions. A is insufficient; C may lack detail; D risks
miscommunication and violates best practices.
Question 4
Which social determinant of health has the greatest impact on a patient's ability
to attend follow-up appointments?
A. Race and ethnicity.
B. Transportation availability.
C. Marital status.
D. Educational level.
Correct Answer: B
Rationale: Lack of transportation is a direct, practical barrier to attending
appointments. While A, C, and D influence health, transportation is most
immediately linked to appointment attendance.
,Question 5
A care coordination nurse is assessing a patient's health literacy. Which question
is most appropriate?
A. "Can you read and write?"
B. "How confident are you filling out medical forms by yourself?"
C. "What is your highest level of education?"
D. "Do you understand English?"
Correct Answer: B
Rationale: The "Single Item Literacy Screener" or confidence-based questions
assess health literacy without shame. A, C, and D do not accurately measure
functional health literacy.
Question 6
A patient is uninsured and needs expensive medications. What is the best
navigation action?
A. Tell the patient to apply for Medicaid.
B. Refer the patient to a social worker for medication assistance programs.
C. Advise the patient to skip doses to save money.
D. Recommend over-the-counter alternatives.
Correct Answer: B
Rationale: Social workers can connect patients to pharmaceutical assistance
programs, patient assistance foundations, and discount programs. A may not be
feasible; C is dangerous; D may be inappropriate.
Question 7
Which action best demonstrates patient advocacy in care coordination?
A. Making decisions for the patient.
B. Ensuring the patient's preferences are included in the care plan.
C. Avoiding discussion of sensitive topics.
D. Limiting family involvement.
, Correct Answer: B
Rationale: Advocacy means ensuring patient preferences and values guide care. A
is paternalistic; C avoids necessary communication; D may exclude important
support.
Question 8
A patient with limited income is prescribed a costly inhaler. Which resource
should the nurse explore first?
A. Emergency department voucher programs.
B. Pharmaceutical manufacturer patient assistance programs.
C. Hospital charity care.
D. Crowdfunding websites.
Correct Answer: B
Rationale: Manufacturer assistance programs often provide free or reduced-cost
medications. A, C, and D are less reliable and not first-line navigation strategies.
Question 9
A care coordination nurse is helping a homeless patient manage hypertension.
Which intervention is most important?
A. Providing a 90-day supply of medication.
B. Connecting the patient with a shelter and food resources.
C. Scheduling weekly clinic visits.
D. Teaching a low-sodium diet.
Correct Answer: B
Rationale: Maslow's hierarchy—basic needs (shelter, food) must be addressed
before chronic disease management. A, C, and D are important but secondary.
Question 10
Which tool is best for identifying patients who need care coordination services?
