Coordination of Care Practice Exam

These questions are part of the practice quiz. Start practicing

• What are key factors for successful patient-family meetings during discharge?
• What is the primary purpose of Medigap?
• How should care teams address health literacy and cultural differences in discharge instructions?
• Name three social determinants of health most commonly addressed in care coordination and why they matter.
• What is the primary purpose of the I PASS the BATON handoff tool?
• What is an effective strategy to reduce readmissions related to medication issues?
• Which role is primarily responsible for coordinating post-discharge follow-up with the primary care physician?
• Which services are covered under Medicare Part A?
• How does patient engagement impact care outcomes in care coordination?
• Which member typically leads care coordination for complex patients in most settings?
• What is the importance of privacy and HIPAA in care coordination?
• Is health literacy determined by grade level completed in school?
• Which step of the care coordination process is focused on tracking progress and outcomes to determine changes?
• Teach-back should be used how?
• When is the HCAHPS survey typically administered?
• How do you identify and manage high-risk patients for care coordination?
• In chronic disease management, what does disease-specific care planning involve?
• In I PASS the BATON, what does the 'Next' component indicate?
• Which practice most directly reduces adverse events during patient transitions?
• Who should be included in discharge teaching?
• What is the role of SBAR in interprofessional communication?
• How is HCAHPS data used at a high level?
• In I PASS the BATON, what does the 'Situation' section cover?
• Define care coordination and its primary goal in a patient-centered medical home.
• What is TeamSTEPPS?
• Why is a multidisciplinary team important in chronic disease management?
• Which of the following is NOT among TeamSTEPPS five key principles?
• Which technique promotes open and safe communication during patient teaching?
• What is the electronic health record (EHR)?
• How can finances act as a barrier to healthcare?
• Provide an example of a patient activation strategy in care coordination.
• What is the Universal Precautions best practice in relation to health literacy?
• Define health literacy and explain its relevance to care coordination.
• What is a key benefit of standardized handoffs across transitions?
• Which statement about health literacy in older adults is supported by the material?
• Which statement about limited health literacy is supported by available data?
• How should medication reconciliation be conducted at transitions of care to prevent adverse drug events?
• What are key topics to cover in discharge teaching beyond medications?
• What is the primary purpose of a care plan in coordinating care?
• In I PASS the BATON, what does the 'Patient' component include?
• What is the role and development approach of patient education materials in care coordination?
• How many items are in the HCAHPS survey, and what is its purpose?
• What is the best reading level for written health materials, according to AHRQ?
• What is gaps in care and how can teams close them?
• Which of the following is NOT a health literacy practice recommended for clinicians?
• Which of the following is one of the CTM-3 care transition questions in HCAHPS?
• Why is end-of-life care coordination challenging and what strategies improve it?
• Which outcome is most aligned with value-based care in care coordination?
• How does patient education contribute to reducing readmissions?
• What is the primary goal of care coordination?
• What is the purpose of a medication reconciliation checklist?
• How does telemonitoring contribute to ongoing care coordination for chronic illness?
• What is the purpose of a care coordination "hotline" or central contact point?
• Which practice specifically helps prevent medication-related hospitalizations by ensuring accurate medications across settings?
• In I PASS the BATON, what information belongs in the 'Background'?
• Privacy and confidentiality in sharing patient information across the care team should be handled in accordance with which framework, and what principles apply?
• What is the difference between primary care and care coordination in terms of responsibilities?
• In I PASS the BATON, which elements are included in the 'Assessment' component?
• In I PASS the BATON, what does the 'Safety' section include?
• Which Parts comprise Medicare?
• Which statement about Medicare Part C (Medicare Advantage) is true?
• Which phrase is preferred to describe high blood pressure to improve health literacy?
• Which item is NOT typically included in a patient-centered care plan?
• Which factor best describes a social determinant of health that can hinder care coordination?
• Which patient risk factor most strongly predicts readmission risk?
• What is telehealth's role in care coordination?
• When does discharge planning begin for hospitalized patients?
• What is the role of health information exchange (HIE) in care coordination?
• What is an example of a population health approach in care coordination?
• Which action most directly reduces hospital readmissions in care coordination programs?
• What outcome is most likely improved by effective care coordination?
• Which appointment instruction uses plain language to avoid confusion?
• Which of the following is a health literacy skill or attribute that influences health literacy?
• What effect does bedside shift report have on trust and anxiety?
• How does a patient navigator contribute to care coordination for underserved populations?
• What does the SBAR framework stand for in clinical communication?
• What is the purpose of risk stratification in population health?
• In I PASS the BATON, what does the 'Actions' component describe?
• Which statement best describes patient activation measures?
• Which statement best describes interoperability in health IT?
• What is boundary-spanning coordination and why is it important in care coordination?
• What is DESC in TeamSTEPPS and what are its steps?
• Which of the following is NOT a recommended health literacy practice?
• Which step of the care coordination process specifically involves creating a tailored plan based on assessed patient needs?
• What is the possible penalty size under HRRP?
• What is the goal of readmission reduction programs, and how does care coordination contribute?
• Which approach reduces medication-related hospitalizations?
• What areas does the HCAHPS survey capture?
• Which statement best describes secure transmission in sharing health information?
• To align care coordination outcome measures with payer requirements, which approach is best?
• Medicare is structured into which parts?
• What is the HCAHPS survey?
• Which metric best assesses readmission risk and outcomes in care coordination programs?
• What is care gaps closure, and how can teams track it effectively?
• Which step of the care coordination process is primarily about putting the plan into action?
• What is a primary mechanism by which the Hospital Readmissions Reduction Program influences hospital behavior?
• Which data element is most critical for a successful transition of care?
• In evaluating care coordination programs, which measure best reflects patient experience?
• Why is conducting iterative improvement in care processes important?
• What are the three questions patients are encouraged to ask their health care providers under the Ask Me 3® framework?
• In I PASS the BATON, what does the 'Intro' component require?
• What defines health literacy?
• Can health literacy be determined by grade completed in school?
• Which of the following is identified as a barrier to healthcare?
• What is the role of a care coordination dashboard?
• How does health information exchange (HIE) support coordination of care?
• In rural care coordination, how does telemedicine help?
• Which statement best describes culturally competent care in terms of language access?
• Which outcomes are commonly used to align with payer requirements?
• What response scale is used for nurse and doctor questions in HCAHPS?
• Which practice best integrates patient preferences into decision making for care plans?
• Which statements about Medigap are true?
• How does social work differ from disease management in care coordination?
• What major update occurred to the HCAHPS survey in 2025?
• Which strategy most effectively enhances patient engagement in self-management?
• Which of the following is a data governance practice important in a care coordination program?
• Which action is least effective in reducing adverse drug events in a care coordination setting?
• Which of the following is one of the four teachable learning skills in TeamSTEPPS?
• Is there a separate survey for home health organizations in addition to HCAHPS?
• In the new Part D structure, at which point does the beneficiary pay $0 for the rest of the year?
• Medicare Part D covers what, and what is typical arrangement?
• Why is medication reconciliation critical at discharge?
• In the ABCD mnemonic for Medicare, what does 'Combined' refer to?
• In care coordination for diabetes transitions, what is the role of nutrition support?
• What roles do pharmacists play in care coordination?
• How does the concept of value-based care influence care coordination strategies?
• Which practice during discharge reduces readmission risk?
• Which type of data is essential for risk stratification in care management programs?
• In the United States, health-related information is typically written at or above which grade level, and what grade level should materials be written in according to the AHRQ?
• A patient-centered care plan is important because it aligns goals with patient preferences and coordinates services. Which statement best describes its essential components?
• What is the primary action of social workers in housing instability within care coordination?
• What are care transitions and why are they high risk?
• What is a personal health record (PHR)?
• What is the primary shift in TeamSTEPPS 3.0 regarding team structure?
• What is a key benefit of bedside shift reporting for patient engagement?
• How can a care team measure patient activation or engagement levels?
• Which communication framework is most commonly used to standardize handoffs between providers?
• What is medication reconciliation and at which points of care should it occur?
• Which component is essential for coordinating post-acute care services?
• In multidisciplinary care, what does a RACI matrix help clarify?
• How can a team ensure culturally competent care coordination?
• What is the approximate average reading level of U.S. adults according to AHRQ?
• Who is generally covered under Medicare?
• Which factors are used in risk stratification for care coordination?
• Limited health literacy is associated with what outcomes?
• Health literacy is defined as which?
• Which metrics are commonly used to evaluate the success of care coordination programs?
• Which practice supports health literacy in care coordination?
• Which statement about boundary-spanning coordination is most accurate?
• How can care coordination improve medication safety for older adults with polypharmacy?
• What is the role of health literacy in care coordination?
• In care coordination, what is the purpose of formal handoffs between disciplines?
• What is the electronic medical record (EMR)?
• Which data element is least essential for meaningful risk stratification in care management?
• What is Ask Me 3®?
• Describe a typical care coordination workflow for a patient with congestive heart failure after hospital discharge.
• How have HCAHPS scores been used by CMS?
• Why is mutual support important in TeamSTEPPS?
• Medicare Part B covers which of the following and typically covers what percent?
• How can a pharmacist integrate with care coordination to reduce adverse drug events?
• What is 'care gap closure' and how is it tracked?
• In TeamSTEPPS 3.0, how is the patient defined?
• Which barrier most commonly impedes effective handoffs across care settings?
• Which statement best distinguishes a proactive care management outreach from a clinician-initiated referral?
• Which statement best describes the role of care coordination within a patient-centered medical home?
• How should care coordination adapt to the needs of patients with mental health comorbidities?
• Which option correctly lists the six steps of the care coordination process model?
• Where is HCAHPS data published?
• Which statement best describes the role of health literacy in coordinating care?
• What is the show-me method in health literacy?
• What is the significance of standardizing handoffs between settings?
• How can digital decision support tools assist care coordination?
• In care transitions, which practice most effectively reduces readmission risk?
• What is medication reconciliation and when should it occur?
• Explain the difference between a care plan and a treatment plan in care coordination.
• What is the role of standardized tools (checklists, flow sheets) in coordination of care?
• Which practice supports communication with LEP patients?
• How does an accountable care organization (ACO) support care coordination?
• Which condition is targeted by HRRP's 30-day readmission measures?
• What happened to the donut hole in Medicare Part D?
• Which action is essential to optimize care transitions for patients with diabetes?
• Distinguish between Chronic Care Management (CCM) and Transitional Care Management (TCM) in terms of focus and billing.
• What ethical considerations arise in care coordination when balancing patient autonomy and safety?
• Which element is essential in discharge planning to prevent readmission?
• What is a patient-centered medical home (PCMH) and its relevance to care coordination?
• Which element is not typically part of a Transition of Care protocol?
• Which outcome is most directly improved by effective care transitions?
• Telemonitoring enables proactive actions by triggering outreach when what occurs?
• How many hospitals participate in HCAHPS, and how many patients are represented annually?
• Which statement about patient-reported outcomes (PROs) in care coordination is most accurate?
• In data governance, what is the primary purpose of data sharing agreements between providers?
• In a patient with multiple chronic conditions, which approach best supports effective care coordination?
• What is a Transition of Care (TOC) protocol and its key elements?
• What is a common challenge of care coordination in rural settings?
• What is a key benefit of early palliative care integration in end-of-life care coordination?
• Who should be involved in discharge planning?
• Which element best describes a care coordination dashboard?
• Which member of the care team typically leads the care coordination process for high-risk patients and coordinates services across settings?
• In I PASS the BATON, what does the 'Timing' component address?
• Which statement best describes the role of standardized care planning in reducing fragmentation?
• What does CUS stand for in TeamSTEPPS and what is its purpose?
• Which statement best differentiates a case manager from a social worker in care coordination?
• What is the purpose of the teach-back method in patient education?
• Which is the best approach to handling duplicate tests when coordinating care?
• For most complex patients, which disciplines should be included in a multidisciplinary care coordination team?
• What role does patient education play in reducing hospital readmissions?
• What data access principle should govern sharing patient information within the care team?
• What outcome do readmission reduction programs target?
• Which statement reflects one of the three questions encouraged by the Ask Me 3 framework?
• Which outcome is most directly supported by efficient health information exchange?
• Describe the impact of caregiver burden on care coordination outcomes.
• Which practice helps minimize information overload when communicating health information?
• What is a care plan's SMART goal and why is it important?
• In chronic disease management, what is disease-specific care planning?
• Which statement best describes the primary aim of care coordination in health care systems?
• Which approach best ensures care activities align with patient goals?
• Which statement best describes the role of a care dashboard or registry in care coordination?
• Which ongoing process is used to improve care coordination through iterative testing and learning?
• What describes best practices for shift handoff?
• Which step helps ensure LEP patients receive appropriate language services?
• Why is HRRP significant in the shift toward value-based care?
• What is comprehensive discharge planning and why is it critical for reducing readmissions?
• Which statement best describes proactive outreach in care coordination for patients with chronic conditions?
• Does being anxious affect a person's ability to use health information?
• What best describes the difference between a referral and proactive care management outreach?
• How do social workers and care coordinators collaborate to address housing instability?
• How does HCAHPS affect reimbursement and value-based care?
• How can care coordination support medication adherence in patients with limited health literacy?
• How can telehealth support care coordination, and what are potential limitations?
• What is the purpose of medication reconciliation in discharge planning?
• Limited health literacy is associated with which of the following outcomes?
• What is the difference between continuous care management and episodic care?
• Why is handoff standardization critical during transitions?
• Which word is recommended instead of 'abdomen' to improve understanding?
• Which tools help ensure patient understanding and adherence to the care plan?
• Which statement best describes the ongoing goals of care coordination across settings?
• Which of the following is a common barrier to effective care coordination?
• Which statement about Part A premiums and deductibles is true?
• In I PASS the BATON, what does the 'Ownership' component refer to?
• Which limitation is commonly associated with telehealth in care coordination?