Chronic disease management models and complex case stratification concepts tested on the CCM certification exam.
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- What chronic disease management model uses a multidisciplinary team to proactively manage patients?
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The Chronic Care Model- What does the Chronic Care Model emphasize as central to improving outcomes?
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Productive interactions between an informed, activated patient and a prepared, proactive practice team- What is case stratification in complex care management?
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Sorting patients by risk level and complexity to allocate case management resources appropriately- What population is typically the focus of high-risk or complex care case management programs?
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Patients with multiple chronic conditions, high healthcare utilization, or high cost of care- What is a comorbidity?
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The presence of one or more additional health conditions alongside a primary condition- What is self-management support in chronic disease management?
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Helping patients develop the skills and confidence to manage their own condition day to day- What technique is commonly used to assess and strengthen a patient's readiness to change health behaviors?
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Motivational interviewing- What is polypharmacy?
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The use of multiple medications by a patient, often increasing the risk of interactions and side effects- What is medication reconciliation?
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The process of comparing a patient's medication orders to all medications the patient is actually taking to resolve discrepancies- What is the purpose of a care plan in chronic disease case management?
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To document individualized goals, interventions, and responsible parties for managing a patient's condition- What is a health risk assessment used for?
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To identify a patient's risk factors and guide targeted interventions- What is predictive modeling used for in complex case management programs?
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To identify patients likely to have high future healthcare costs or utilization- What is the goal of transitional care management?
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To reduce readmissions and complications by coordinating care during the transition between care settings- What are the chronic diseases most often targeted by disease management programs?
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Diabetes, heart failure, and chronic obstructive pulmonary disease (COPD)- What complications do case managers commonly monitor for in diabetes management?
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Hypoglycemia, neuropathy, retinopathy, and nephropathy
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