ACM-RN cheat sheet
ACM-RN · Keep the key ideas within reach.
Care Management and Coordination
Case management process: screening, assessment, care planning, implementation, coordination, monitoring, evaluation, and transition.
Risk stratification uses tools like the LACE index (Length of stay, Acuity, Comorbidity, Emergency department visits) to predict 30-day readmission risk.
The Patient Activation Measure (PAM) assesses patient knowledge, skills, and confidence for self-management; higher levels correlate with better outcomes.
Motivational interviewing uses OARS: Open-ended questions, Affirmations, Reflections, and Summaries to build collaboration.
SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound.
Care coordination includes medication reconciliation, transition planning, and communication among providers, patients, and caregivers.
The Chronic Care Model includes six elements: health system, community resources, self-management support, delivery system design, decision support, and clinical information systems.
Interprofessional collaboration requires role clarity, shared goals, and structured communication (e.g., SBAR: Situation, Background, Assessment, Recommendation).
Patient Advocacy and Education
Teach-back method: patient explains information in own words; confirms understanding and identifies gaps.
Health literacy universal precautions: assume all patients may have limited health literacy; use plain language and pictures.
Patient Self-Determination Act (1990) requires hospitals to inform patients of advance directives and document them.
Advocacy includes protecting patient autonomy, privacy (HIPAA), and access to needed services.
Shared decision-making integrates patient values with clinical evidence using tools like decision aids.
The README model: Review, Explain, Assess, Document, and Evaluate for patient education.
Cultural competence: awareness of one's own biases, knowledge of patient's culture, and adapting care accordingly.
Barriers to learning include low literacy, hearing/vision impairment, language, pain, anxiety, and readiness to learn.
Transitions of Care
Transitional care model focuses on comprehensive discharge planning and follow-up by advanced practice nurses.
Medication reconciliation is a formal process of obtaining a complete and accurate list of all medications and comparing it across transitions.
The Care Transitions Intervention (Coleman) uses a transition coach and a personal health record to promote self-management.
Risk factors for poor transitions: polypharmacy, low health literacy, lack of social support, multiple chronic conditions, and recent hospitalization.
Discharge planning should begin at admission and include patient/caregiver education, follow-up appointments, and community referrals.
The INTERACT program (Interventions to Reduce Acute Care Transfers) uses tools to identify and manage changes in condition in nursing homes.
Post-discharge follow-up call within 48-72 hours can reduce readmissions by addressing questions and medication issues.
Warm handoff: direct communication between outgoing and incoming providers to ensure continuity.
Psychosocial and Behavioral Health
Erikson's stages: each stage has a psychosocial crisis; successful resolution leads to a virtue (e.g., trust vs. mistrust in infancy).
Screening tools: PHQ-9 for depression, GAD-7 for anxiety, AUDIT-C for alcohol use, CAGE for substance use.
SBIRT: Screening, Brief Intervention, and Referral to Treatment for substance use.
Stages of change (Prochaska & DiClemente): precontemplation, contemplation, preparation, action, maintenance, and relapse.
Mental Health Parity and Addiction Equity Act requires equal coverage for mental health and substance use disorders.
Therapeutic communication techniques: active listening, empathy, open-ended questions, reflection, and summarization.
Suicide risk assessment includes direct questioning about ideation, plan, intent, and means; safety planning is essential.
Social determinants of health (SDOH) include economic stability, education, social support, health care access, and neighborhood environment.
Chronic and Complex Care Management
The 5 A's for behavior change: Assess, Advise, Agree, Assist, and Arrange follow-up.
Self-management support includes education, skills training, and problem-solving to help patients manage chronic conditions.
The chronic care model emphasizes productive interactions between informed, activated patients and prepared, proactive teams.
Polypharmacy management includes regular medication reviews, deprescribing, and considering Beers Criteria for older adults.
The Wagner Chronic Care Model is often implemented with the Patient-Centered Medical Home (PCMH) model.
Care management for complex patients often includes interdisciplinary team meetings and individualized care plans.
The HEDIS measures (e.g., HbA1c control, blood pressure control) are used to evaluate chronic care quality.
Risk factors for complex care needs: multiple chronic conditions, functional limitations, social isolation, and frequent hospitalizations.
Program Evaluation, Quality, and Outcomes
Donabedian model: Structure, Process, and Outcomes for evaluating quality of care.
The IOM (Institute of Medicine) six aims for improvement: safe, effective, patient-centered, timely, efficient, and equitable.
PDSA cycle: Plan, Do, Study, Act for continuous quality improvement.
Quality measures: process measures (e.g., screening rates), outcome measures (e.g., readmission rates), and balancing measures.
Root cause analysis (RCA) is used for sentinel events; failure mode and effects analysis (FMEA) is proactive.
Benchmarking compares performance to best practices or standards.
Statistical process control (SPC) charts differentiate common-cause and special-cause variation.
Return on investment (ROI) = (Net benefit / Cost) x 100; used to evaluate program value.
Legal, Ethical, and Professional Practice
HIPAA Privacy Rule protects individually identifiable health information; minimum necessary standard applies.
Informed consent requires capacity, disclosure, understanding, voluntariness, and consent.
Mandatory reporting: suspected abuse/neglect of children, older adults, and dependent adults; certain communicable diseases.
Ethical principles: autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity.
The Nurse Practice Act defines scope of practice and is regulated by state boards of nursing.
Advance directives include living wills, durable power of attorney for health care, and DNR orders.
Confidentiality exceptions: duty to warn, public health reporting, and court orders.
Professional boundaries: avoid dual relationships, maintain objectivity, and protect patient dignity.