Care Monitoring & Protocols Factors

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Care monitoring & protocols factors are elements of the care management factors in patient recovery.

Recovery Plan Activities

  • Activities, treatments are scheduled and are taking place
  • Medication - medication reconciliation, prescriptions filled, refilled, etc.
  • Recovery Team - performs function
  • Status - Surgeries, Procedures, Tests, Therapies, etc.

Patient Adherence

  • Medication Adherence
  • Activity levels
  • other patient behaviors, etc.

Patient Activation

  • Understand condition
  • Capable of treating self, etc.
  • Technology - have appropriate technology (i.e., wifi Blood pressure cuff), understand how to use it

Recovery Factors Monitored

  • Clinical Condition Factors - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.
  • Social and Behavioral Factors
  • Basic Needs Factors

Monitoring Method

  • Daily Calls, IVR
  • Onsite visits
  • Patient device input - checks box or inputs data
  • Device Sensors - Blood pressure cuffs, wifi enabled bathroom scale
  • Passive sensors (wifi enabled pill boxes or caps)

Recovery Plan Effectiveness

  • Medication efficacy (effectiveness, interactions, adverse events),
  • Treatments, procedures, tests, etc.
  • Activities,
  • Recovery team,
  • Protocols
  • Appropriateness of Recovery Goals

Recovery protocols factors are elements of the recovery management factors in patient recovery.

Event Triggers

Event Triggers Requiring Notifications

  • Patient Concern
  • Monitoring Alert - Medication adherence, blood pressure reading, etc.
  • Patient Dialog
  • Patient Input
  • Clinical Condition
  • Emergency
  • Transfer Event (i.e., Hospital to home)

Event Notification

  • Who - is notified based on each trigger (Patient, Care Giver, Recovery Navigator, Care Manager)
  • How - phone calls, text message, alerts
  • When - notification time frame

Associated Action

  • Who - takes the action
  • What - is the action?
  • How - phone calls, text message, alerts
  • When - notification time frame

Potential actions include:

  • Patient triage
  • Conduct on-site assessment
  • Issue Escalation
  • Reassess Recovery Goals, Plan, Monitoring & Protocols
  • Achieve confirmation to change Recovery Goals, Plan, Monitoring and Protocols

Escalation

  • What - gets escalated
  • Who - escalates it (nurse, patient)
  • Whom - do they escalate to (doctor, nurse)?
  • When - do they escalate
  • How - do they escalate

Protocol Monitoring

  • Who - ensure notifications, actions and escalations are happening
  • How
  • When - do they escalate based on inaction