Free CPHQ Population Health and Care Transitions Practice Questions

This domain represents 8.8% of CPHQ. Topics include population outcomes, care coordination, risk stratification, transitions, access, equity, and continuity of care.

Sample Question 1 — Population Health and Care Transitions

A health system wants to characterize the health status of the population in its primary service area. Which data source is the most appropriate starting point?

  1. A. Patient satisfaction survey results from the system's clinics
  2. B. Community health needs assessment data for the service area (Correct answer)
  3. C. Results of the system's employee health screening program
  4. D. Inpatient discharge summaries from the past year

Correct answer: B

Explanation: B is correct because a community health needs assessment compiles population-level health status, demographics and community conditions for a defined geography. A is incorrect because satisfaction describes the experience of those who received care, not population health status. C is incorrect because employees are not representative of the community the system serves. D is incorrect because discharge data describe patients who were admitted rather than the health of the whole population.

Sample Question 2 — Population Health and Care Transitions

A population health team needs to identify the chronic conditions most prevalent among patients attributed to its primary care network. Which data would be most useful?

  1. A. Claims and registry data for the attributed patient panel (Correct answer)
  2. B. Emergency department visit volumes for the surrounding county
  3. C. Encounter notes from the most recent month of primary care visits
  4. D. Results from the organization's most recent employee wellness screening

Correct answer: A

Explanation: A is correct because claims and disease registry data cover the full attributed panel, including care delivered elsewhere, which prevalence estimation requires. B is incorrect because county-level utilization does not identify conditions among the network's attributed patients. C is incorrect because one month of visits captures only patients who happened to present and omits the rest of the panel. D is incorrect because employees are a different population from the attributed patient panel.

Sample Question 3 — Population Health and Care Transitions

Before measuring the health status of a population, what is most important to establish?

  1. A. That the population aligns with the organization's billing categories
  2. B. That every individual has had at least one visit in the past month
  3. C. Explicit inclusion and exclusion criteria for membership in the population (Correct answer)
  4. D. That the population contains at least one thousand individuals

Correct answer: C

Explanation: C is correct because a population measure is interpretable only when it is clear who is counted in it and who is not. A is incorrect because billing categories serve financial classification and may not correspond to a meaningful population. B is incorrect because that is one possible criterion rather than the general requirement that criteria be explicit. D is incorrect because an arbitrary minimum size does not make the population definition clear or meaningful.

Sample Question 4 — Population Health and Care Transitions

A team reports that diabetes prevalence in its attributed panel rose from 8 percent to 11 percent in one year and concludes that the population became sicker. What should the quality professional examine first?

  1. A. Whether the organization's diabetes clinical practice guideline was updated
  2. B. Whether the laboratory changed its reference range for glycemic testing
  3. C. Whether case finding, coding practice or panel composition changed (Correct answer)
  4. D. Whether patient satisfaction with diabetes care declined during the period

Correct answer: C

Explanation: C is correct because an apparent prevalence change often reflects improved identification, altered coding or a shift in who is attributed rather than a true change in disease burden. A is incorrect because a treatment guideline affects management of identified cases rather than how many cases are counted. B is incorrect because that is one narrow possibility and does not address the broader measurement and attribution issues. D is incorrect because satisfaction has no bearing on how many patients carry the diagnosis.

Sample Question 5 — Population Health and Care Transitions

What is the purpose of risk stratification in population health management?

  1. A. Ranking clinicians according to the outcomes of the patients they treat
  2. B. Excluding the highest-cost patients from population measures
  3. C. Grouping a population by level of need so resources can be matched to each group (Correct answer)
  4. D. Determining which patients are eligible for the organization's health plans

Correct answer: C

Explanation: C is correct because risk stratification sorts a population by predicted need, allowing the most intensive resources to go where they will do the most good. A is incorrect because that describes practitioner profiling rather than stratifying a patient population. B is incorrect because stratification organizes a population for management rather than removing patients from it. D is incorrect because eligibility determination is an administrative function unrelated to clinical risk grouping.

Sample Question 6 — Population Health and Care Transitions

A network wants to reduce avoidable emergency department use among its highest-need patients. Which strategy is most appropriate?

  1. A. Targeted care management outreach to the highest-risk stratum (Correct answer)
  2. B. Adding a copayment for emergency department visits judged non-urgent
  3. C. A mailing to all attributed patients on when to use the emergency department
  4. D. Extending emergency department hours to reduce patient waiting times

Correct answer: A

Explanation: A is correct because directing intensive care management at the small group generating most avoidable use concentrates effort where the return is greatest. B is incorrect because a financial barrier may deter necessary care and does not address the underlying unmet need. C is incorrect because an untargeted mailing reaches mostly low-risk patients and is a weak intervention for complex need. D is incorrect because that addresses capacity within the department rather than preventing avoidable visits.

Sample Question 7 — Population Health and Care Transitions

A population health strategy is being integrated into an improvement initiative that is already under way. What best supports its success?

  1. A. Creating a separate committee and reporting structure for the strategy
  2. B. Deferring the strategy until the current improvement initiative closes
  3. C. Assigning the strategy to the population health department exclusively
  4. D. Aligning the strategy with measures the initiative already tracks and reports (Correct answer)

Correct answer: D

Explanation: D is correct because building on existing measurement avoids parallel systems and allows the strategy to be evaluated within work already in motion. A is incorrect because parallel structures fragment accountability and duplicate effort. B is incorrect because delay forgoes the opportunity to embed the strategy in active work. C is incorrect because population health strategies require participation from the clinical areas that deliver care.

Sample Question 8 — Population Health and Care Transitions

A care management program reports better outcomes for enrolled patients than for those who declined enrollment. Enrollment is voluntary. What most limits the conclusion that the program caused the improvement?

  1. A. The outcome being measured varies seasonally
  2. B. Outcomes were recorded by staff working within the program
  3. C. The enrolled group did not contain enough patients for analysis
  4. D. Patients who enroll differ systematically from those who decline (Correct answer)

Correct answer: D

Explanation: D is correct because when participation is voluntary, enrollees differ in ways that independently predict better outcomes, so the comparison does not isolate the program's effect. A is incorrect because seasonal variation would affect both groups and cannot explain a difference between them. B is incorrect because who records an outcome is a separate concern from the systematic difference between enrollees and decliners. C is incorrect because the problem lies in the composition of the groups rather than the number of patients in them.

Sample Question 9 — Population Health and Care Transitions

Which of the following is an example of secondary prevention?

  1. A. Immunizing children against a communicable disease
  2. B. Providing rehabilitation to restore function after a stroke
  3. C. Screening asymptomatic adults to detect disease at an early stage (Correct answer)
  4. D. Educating the public about the health risks of tobacco use

Correct answer: C

Explanation: C is correct because secondary prevention detects disease before symptoms appear so that treatment can begin earlier. A is incorrect because preventing disease from occurring at all is primary prevention. B is incorrect because limiting disability from established disease is tertiary prevention. D is incorrect because reducing exposure to a risk factor before disease develops is primary prevention.

Sample Question 10 — Population Health and Care Transitions

What distinguishes disease management from case management?

  1. A. Disease management is voluntary whereas case management is mandatory
  2. B. Disease management applies to inpatients and case management to outpatients
  3. C. Disease management is delivered by physicians and case management by nurses
  4. D. Disease management addresses a population, case management an individual (Correct answer)

Correct answer: D

Explanation: D is correct because disease management applies a standardized approach to everyone with a given condition, whereas case management coordinates services for one person. A is incorrect because participation in either depends on program design rather than on a general rule. B is incorrect because both occur across care settings. C is incorrect because the distinction lies in scope rather than in the discipline that delivers the service.

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