Advanced Pharmacology WGU D116 - Unit 5 Transition of
Care Knowledge test Exam Toolkit Questions and Verified
solution 2025/2026
According to CMS guidelines, how soon after discharge from a hospital setting should a
patient be contacted for initial Transitional Care Management [TCM] services correct
answer
Within 2 business days
The Institute for Healthcare Improvement [IHI]"Triple Aim" of healthcare is often
mentioned in the context of Transitional Care Management [TCM]. What are the three
aims correct answer
Improved patient care, population health, and reduced costs
All of the following are standard interventions that should be implemented for a hospital
inpatient who is at high risk for readmission except for:
Early identification of a primary caregiver to include in educational sessions
Using teachback with visual and written evidence-based teaching materials
Perform medication reconciliation upon admission
Scheduling all follow up appointments prior to discharge
Studies have shown that successful TCM programs often rely on collaboration between
which healthcare professionals correct answer
, Nurse practitioners, physicians, and social workers
What is one of the biggest challenges to implementing effective TCM programs in
today's healthcare landscape correct answer
Lack of awareness about TCM benefits &
Difficulty in coordinating care across different providers
An 82-year-old patient with chronic heart failure and dementia is being discharged from
the hospital to a skilled nursing facility (SNF) after a week-long stay for pneumonia
treatment. The patient requires assistance with most activities of daily living (ADLs) and
has a history of falls. According to CMS guidelines, which of the following actions is
MOST important to ensure a smooth transition for this patient correct answer
Ensuring a comprehensive discharge plan is communicated to the SNF staff, including
medication reconciliation, fall risk assessment, and a plan for ongoing dementia
management.
A 75-year-old patient with diabetes and recent amputation of their right leg is
considering transitioning to a long-term care facility. The patient is independent with
most ADLs but requires assistance with dressing and wound care for the amputation
site. From a CMS perspective, which factor should be considered the HIGHEST priority
when evaluating this patient's suitability for a long-term care placement correct answer
The SNF's ability to provide appropriate wound care services and physical therapy for
the patient's specific needs.
A 68-year-old patient with a history of stroke is medically stable after a hospital stay and
is interested in returning home. However, the patient's spouse is unable to provide all
the necessary daily support due to their own health limitations.When discussing long-
term care options with this patient, which of the following statements is MOST aligned
with CMS guidelines regarding patient-centered care correct answer
Care Knowledge test Exam Toolkit Questions and Verified
solution 2025/2026
According to CMS guidelines, how soon after discharge from a hospital setting should a
patient be contacted for initial Transitional Care Management [TCM] services correct
answer
Within 2 business days
The Institute for Healthcare Improvement [IHI]"Triple Aim" of healthcare is often
mentioned in the context of Transitional Care Management [TCM]. What are the three
aims correct answer
Improved patient care, population health, and reduced costs
All of the following are standard interventions that should be implemented for a hospital
inpatient who is at high risk for readmission except for:
Early identification of a primary caregiver to include in educational sessions
Using teachback with visual and written evidence-based teaching materials
Perform medication reconciliation upon admission
Scheduling all follow up appointments prior to discharge
Studies have shown that successful TCM programs often rely on collaboration between
which healthcare professionals correct answer
, Nurse practitioners, physicians, and social workers
What is one of the biggest challenges to implementing effective TCM programs in
today's healthcare landscape correct answer
Lack of awareness about TCM benefits &
Difficulty in coordinating care across different providers
An 82-year-old patient with chronic heart failure and dementia is being discharged from
the hospital to a skilled nursing facility (SNF) after a week-long stay for pneumonia
treatment. The patient requires assistance with most activities of daily living (ADLs) and
has a history of falls. According to CMS guidelines, which of the following actions is
MOST important to ensure a smooth transition for this patient correct answer
Ensuring a comprehensive discharge plan is communicated to the SNF staff, including
medication reconciliation, fall risk assessment, and a plan for ongoing dementia
management.
A 75-year-old patient with diabetes and recent amputation of their right leg is
considering transitioning to a long-term care facility. The patient is independent with
most ADLs but requires assistance with dressing and wound care for the amputation
site. From a CMS perspective, which factor should be considered the HIGHEST priority
when evaluating this patient's suitability for a long-term care placement correct answer
The SNF's ability to provide appropriate wound care services and physical therapy for
the patient's specific needs.
A 68-year-old patient with a history of stroke is medically stable after a hospital stay and
is interested in returning home. However, the patient's spouse is unable to provide all
the necessary daily support due to their own health limitations.When discussing long-
term care options with this patient, which of the following statements is MOST aligned
with CMS guidelines regarding patient-centered care correct answer
