ACM cheat sheet

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services that meet an individual's health needs.

Core case management functions: screening and risk stratification, assessment, care planning, implementation, monitoring and evaluation, outcome measurement, and case closure.

Common models include brokerage, primary therapist, interdisciplinary team, strengths-based, chronic care, and transitional care models; model choice follows population need and setting.

Risk stratification typically uses three tiers - universal (all patients), targeted (at risk), and intensive (high risk/complex) - to set the frequency and depth of case manager contact.

The Naylor Transitional Care Model uses advanced practice nurses for pre-discharge assessment plus post-discharge follow-up in the home or clinic.

The Coleman Care Transitions Intervention rests on four pillars: medication self-management, a personal health record, a follow-up provider visit, and recognition of red flags.

Case managers function as advocates, brokers, coordinators, educators, counselors, and facilitators within an interdisciplinary team.

Case management practice spans the continuum - acute, post-acute, ambulatory, and community - and is delivered by both RN and social work case managers.

Assessment domains: physical/medical, functional (ADLs and IADLs), cognitive, psychosocial, behavioral, environmental, financial, caregiver, and spiritual.

The Katz Index and Barthel Index measure independence in basic ADLs; the Lawton scale measures instrumental activities such as shopping, finances, and medication management.

PHQ-9 score bands: 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe depression; the two-item PHQ-2 serves as the initial screen.

The Mini-Cog combines three-item recall with a clock drawing; a score of 0-2 indicates likely cognitive impairment and warrants fuller evaluation.

The Braden Scale estimates pressure injury risk and the Morse Fall Scale estimates fall risk; scores drive selection of goals and interventions.

Care plan goals should be SMART: specific, measurable, achievable, relevant, and time-bound.

Medication reconciliation compares the pre-admission medication list with current orders and resolves discrepancies at admission, transfer, and discharge.

The LACE index (length of stay, acuity, comorbidity, emergency visits) stratifies 30-day readmission risk and helps target care coordination intensity.

CMS Conditions of Participation require discharge planning to begin early in the stay, be based on an assessment, and include the patient's choice among post-acute providers.

Traditional Medicare Part A covers skilled nursing facility care after a qualifying three-day inpatient stay; observation days do not count toward the three days.

Inpatient rehabilitation facilities require a need for intensive therapy (generally three hours daily), physician oversight, and compliance with the 60% rule for qualifying conditions.

Home health eligibility requires homebound status, an intermittent skilled nursing or therapy need, a physician plan of care, and a face-to-face encounter.

Medicare hospice eligibility requires a prognosis of six months or less if the illness runs its normal course, with palliative rather than curative treatment.

Long-term acute care hospital admission generally requires complex medical needs such as prolonged mechanical ventilation with an expected length of stay of 25 days or more.

Evidence-based transition interventions include Project RED, the Care Transitions Intervention, and the Transitional Care Model.

High-risk discharge practices include medication reconciliation, a follow-up appointment within seven days, teach-back, and written red-flag instructions.

Medicare Part A covers inpatient hospital, skilled nursing, hospice, and some home health; Part B covers physician and outpatient services; Part C is Medicare Advantage; Part D covers outpatient drugs.

MS-DRG payment is a prospective bundled per-discharge payment based on the assigned DRG, with outlier payments for unusually costly cases.

Under the two-midnight rule, inpatient admission is appropriate when the physician expects the stay to span at least two midnights; otherwise the patient is outpatient or observation.

Condition Code 44 allows a hospital to convert an inpatient stay to outpatient status when utilization review finds inpatient criteria were not met.

An Advance Beneficiary Notice is issued to a Medicare Part B beneficiary when a service may be denied as not medically necessary; a signed ABN shifts liability to the patient.

InterQual and Milliman Care Guidelines are evidence-based criteria sets used to determine medical necessity and the appropriate level of care.

Payment models include fee-for-service, per diem, case rate/DRG, capitation, and bundled payment; each creates different incentives for length of stay and resource use.

Medicare Secondary Payer rules require establishing primary versus secondary coverage through coordination of benefits before billing.

Common utilization metrics include length of stay, avoidable days, observation rate, denial rate, and case mix index.

The biopsychosocial model assesses biological, psychological, and social contributors to illness and recovery.

Social determinants screening domains include housing instability, food insecurity, transportation, utility needs, interpersonal safety, and financial strain (for example PRAPARE or the AHC HRSN screen).

Stages of change (Prochaska): precontemplation, contemplation, preparation, action, maintenance, and relapse; interventions must match the patient's current stage.

Motivational interviewing uses OARS - open-ended questions, affirmations, reflections, and summaries - to build intrinsic motivation and explore ambivalence.

SBIRT stands for Screening, Brief Intervention, and Referral to Treatment for risky alcohol and drug use.

Advocacy includes protecting autonomy, informed decision-making, confidentiality, and access to culturally and linguistically appropriate services.

Title VI requires language access for patients with limited English proficiency; trained interpreters, not family members, should be used.

Kubler-Ross stages (denial, anger, bargaining, depression, acceptance) are not linear and are not a required sequence in grief.

Structured suicide risk tools such as the C-SSRS guide level-of-risk determination and safety planning.

Core ethical principles: autonomy, beneficence, nonmaleficence, justice, veracity, fidelity, and confidentiality.

Informed consent requires decision-making capacity, disclosure of material risks and alternatives, comprehension, and voluntariness.

Negligence elements: duty, breach of the standard of care, causation, and damages.

HIPAA permits use and disclosure for treatment, payment, and operations and requires disclosure of only the minimum necessary information.

Exceptions to confidentiality include suspected abuse or neglect, communicable disease reporting, and serious threats to identifiable others (Tarasoff).

Advance directives include living wills, durable power of attorney for health care, and portable clinician orders such as POLST or MOLST.

EMTALA requires a medical screening examination and stabilization of an emergency condition regardless of insurance status or ability to pay.

Case managers must report suspected child abuse, elder abuse, and dependent adult neglect under state mandatory reporting laws.

Guardianship or conservatorship is a court-appointed arrangement used only when the patient lacks decision-making capacity and less restrictive alternatives fail.

SBAR stands for Situation, Background, Assessment, Recommendation and is a structured handoff format.

Teach-back confirms comprehension by asking the patient to restate information in their own words.

Health literacy universal precautions call for plain language at roughly a fifth- to sixth-grade reading level plus comprehension checks for every patient.

TeamSTEPPS tools include briefs, huddles, debriefs, the CUS assertion ('I am Concerned, Uncomfortable, this is a Safety issue'), and the two-challenge rule.

Thomas-Kilmann conflict modes: competing, collaborating, compromising, avoiding, and accommodating.

Interdisciplinary team rounds improve coordination; each discipline documents its own assessment and plan.

Cultural humility involves ongoing self-reflection and openness to the patient's cultural context, values, and preferences.

Documentation should be timely, objective, and specific enough to support the care plan and demonstrate medical necessity.

The Donabedian framework evaluates quality through structure (resources), process (activities), and outcomes (results).

Improvement methods: PDSA/PDCA for rapid-cycle testing, Lean for waste reduction, Six Sigma DMAIC for variation reduction, and FMEA for prospective risk analysis.

Root cause analysis is a retrospective, system-focused method used after a sentinel event to identify underlying causes and prevent recurrence.

Measure types include structure, process, outcome, balancing, and patient experience measures such as HCAHPS.

CMS programs linking payment to quality include the Hospital Readmissions Reduction Program, the Hospital-Acquired Condition Reduction Program, and Hospital Value-Based Purchasing.

Control charts distinguish common-cause (random) variation from special-cause (assignable) variation; only special-cause variation typically justifies investigation.

Case management outcome metrics include length of stay, readmission rate, avoidable days, emergency visits, cost per case, patient satisfaction, and functional status.

Never events and sentinel events trigger immediate investigation, disclosure, and reporting according to organizational policy and accreditor requirements.