Patient Recovery
How do you define Patient Recovery?
Patient recovery is when a patient successfully transitions from an acute or adverse chronic state to a recovered or stable chronic state.
- Acute State - something that requires immediate skilled clinical care such as an urgent care or emergency room visit, hospital visit or post acute stay (killed Nursing Facility, Inpatient Rehabilitation, Home Health).
- Adverse Chronic - this is a non-urgent condition that needs to be addressed soon to prevent an acute state. It could be high blood sugar, high blood pressure, kidney disease, COPD, or asthma that is not under control.
- Recovered - is when the acute condition and/or symptoms no longer prevents the patient from doing what they should be capable of doing if they were fully recovered. It could be back to work or enjoying grandchildren soccer games.
- Chronic Stable - is when the chronic conditions such as diabetes (blood sugar), hypertension (blood pressure), COPD (blood oxygen levels) are at the recommended levels and patient can resume activities associated with the desired state.
The patient defines recovery by their quality of life preferences based of what is reasonably possible with their clinical diagnosis and prognosis.
The Healthcare System
Isn’t patient recovery what our healthcare system provides?
It is not what we are paying our healthcare system to do. Even though most providers are trying to do it anyway, we only pay them to provide clinical services. Also, these clinical services only represent 20% of the factors in health outcomes according to the study by the University of Wisconsin. Health plans and employers (or public health organizations) are also harbored by an antiquated reimbursement system tied to services rather than outcomes like patient recovery.
The four primary approaches to care delivery, which are based on our current reimbursement system, are aligned to “services” and treating individual clinical conditions rather than “patient outcomes”:
“Case Management” is not patient recovery – A hospital stay, procedure or physician office visit is a service that needs to be cost effectively managed in a way that benefits a patient. Yet providers must tightly manage to the reimbursement level to remain a going entity just like any other service provider. The hospital and other clinical services providers employ case management, yet this is to cost-effectively manage patient clinical services. Also, most of the time spent by a patient recovering occurs outside the four walls of hospitals or physician offices.
“Utilization Management” is not patient recovery – The most effective health insurance plans ensure patients are getting the appropriate services (medical necessity), at the right level (i.e., how many days, visits), with the right provider (quality, cost) at the right location (quality,cost). Health plans negotiate with providers to create a high quality, cost effective network of providers to ensure patient outcomes and low cost. While utilization management is an effective approach to reduce costs and unnecessary services, it doesn’t necessarily help patient recovery. Again, most of the recovery occurs outside of clinical services.
“Care Management” is not patient recovery – The most effective health insurance plans ensure patients that require many services are provided care management services to ensure care is delivered as efficient as possible (i.e., ensure patient gets an appointment). Care Management by a health plan doesn't make clinical decisions, which is made by the provider and the patient. Care Management helps with the care process, which is not the same as managing patient recovery. i
“Population Health” is not patient recovery – While employers, labor unions, public health organization and insurers are truly interested in improving the health of their populations, they are not directly involved in patient recovery. Preventive care (i.e., immunizations, annual screenings, care gaps), wellness programs (weight loss, exercise, nutrition) and public health initiatives (smoking, alcoholism) are important programs to improve the health of people over time, yet they are not designed to deliver patient recovery.
If the four primary approaches to healthcare services “Case Management”, “Utilization Management”, "Care Management" and “Population Health” are not patient recovery driven, how do will we get there? We start by developing a system aligned to patient recovery for the people using the most services by leveraging:
Innovation
Innovation is emerging in patient recovery. It is coming from the advances evolving in reimbursement, science and technology.
