ACM-RN key terms

A team-based process that identifies people with complex needs, assesses them, plans and coordinates services, and monitors outcomes to improve health and control costs.

The deliberate organization of patient care activities and information sharing among participants to achieve safer, more effective, and more efficient care delivery.

Sorting a population by predicted health risk or cost using data such as diagnoses, utilization, and social factors so resources go to those who need them most.

A structured appraisal of a person's medical, functional, psychological, social, and environmental circumstances that becomes the foundation of an individualized care plan.

A written, person-centered document stating goals, interventions, responsible parties, timelines, and measures of progress, developed collaboratively with the patient and care team.

A group of professionals from different disciplines who share responsibility for a patient's care and coordinate their efforts through joint planning and regular communication.

A person's knowledge, skills, and confidence for managing their own health and health care, which predicts engagement in self-care behaviors.

Teaching and coaching that helps patients build the skills and confidence to manage symptoms, treatments, lifestyle, and emotional consequences of chronic illness day to day.

A collaborative, goal-oriented counseling style that elicits a person's own reasons for change by expressing empathy, developing discrepancy, and supporting autonomy rather than arguing.

The degree to which a person can obtain, process, and understand basic health information and services needed to make appropriate health decisions.

A technique in which the patient explains in their own words what they were told, allowing the clinician to confirm understanding and correct misunderstandings.

A conversation in which clinician and patient exchange information about options, benefits, and preferences and jointly agree on a course of action.

A set of time-limited actions designed to ensure continuity and coordination when patients move between settings, such as hospital to home or home to skilled facility.

A nurse-led, advanced-practice-driven program that provides hospital visits, discharge planning, home follow-up, and continuous clinical support to high-risk patients across an episode of illness.

A formal process of comparing a patient's complete medication list across care settings and resolving discrepancies to prevent omissions, duplications, and dosing errors.

A structured process begun early in a stay that anticipates post-acute needs and arranges services, equipment, education, and follow-up before the patient leaves.

A return hospital stay, often within 30 days of discharge, that may signal gaps in discharge planning, follow-up, or community support.

A public health approach that uses brief validated questions to detect risky substance use, offers short counseling, and refers people needing further care.

A nine-item self-report questionnaire that scores the frequency of depressive symptoms over two weeks and supports detection and monitoring of depression severity.

An approach that recognizes widespread trauma, avoids re-traumatization, and builds safety, trust, choice, and empowerment into all interactions and systems.

Conditions in the environments where people are born, live, learn, work, and age that affect health outcomes, such as housing, food security, income, and transportation.

Helping patients identify, access, and use non-clinical services such as food assistance, transportation, housing, and benefits programs.

A framework for improving chronic illness care through delivery system design, self-management support, decision support, clinical information systems, community linkages, and organizational support.

An unintended injury or harm caused by medical management rather than the patient's underlying condition.

A structured, retrospective investigation that identifies underlying system failures and contributing factors behind an adverse event and yields corrective actions.

A rapid small-scale improvement method in which a change is planned, tested, observed, and refined, then spread or abandoned based on results.

Comparing an organization's performance measures with internal targets or external peers to identify gaps and set improvement priorities.

A metric that reflects the end result of care, such as symptom control, readmission, function, or satisfaction, rather than the process used to deliver it.

A metric that captures whether a recommended care activity was actually delivered, such as screening completion or timely follow-up call.

An ongoing conversation and documentation process in which a person states values, goals, and preferences for future medical care, including surrogate decision-makers.

A legal document, such as a living will or durable power of attorney for health care, that records a person's treatment wishes or names a decision-maker for when they cannot speak.

Federal law that sets national standards for protecting the privacy and security of individually identifiable health information and defines permitted uses and disclosures.

A patient's voluntary agreement to a treatment or procedure after receiving and understanding information about its nature, risks, benefits, and alternatives.

The activities and responsibilities a professional is legally and educationally authorized to perform under state licensure and employer policy.

Acting to protect and promote a patient's rights, preferences, and access to needed care, including speaking up when systems or decisions threaten them.