View source for Care Management Determinants

These are the [[Care Management Determinants|Care Management]] [[Determinants]] that are that can decisively affect [[Patient Well-Being|patient well-being]] and [[Patient Recovery|patient recovery]]. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy.

==[[Care Coordination Factors|Care Coordination]]==
[[Care Coordination Factors|Care coordination factors]] are elements of the [[Care Management Factors|care management factors]] in [[Patient Recovery|patient recovery]]. 
* Communication within [[Care Team Factors|care team]]
* Arranging diagnosis, second opinions, procedures, etc.
* Patient Navigation

==[[Care Decision Making & Goals Factors|Care Decision Making & Goals]]==
[[Recovery Goals Factors|Recovery goals factors]] are elements of the [[Care Management Factors|care management factors]] in [[Patient Recovery|patient recovery]]. 
===Discovery===
* Clinical Consults
* Qualified Option Development
* Testing
===Desired===
* Clinical Condition, 
* Functional Condition, 
* Behavior & Lifestyle

==[[Care Plan & Treatment Factors|Care Plan & Treatment]]==
[[Recovery Plan Factors|Recovery plan factors]] are elements of the [[Care Management Factors|care management factors]] in [[Patient Recovery|patient recovery]]. 
===Treatments===
* Medicine
* Procedures
* Surgery
* Therapies (Occupational Therapy, Speech, Physical Therapy)
===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.
* Nutrition
* Education

==[[Recovery Monitoring Factors|Care Monitoring & Protocols]]==
[[Recovery Monitoring Factors|Care Monitoring & Protocols]] are elements of [[Care Management Factors|care management]] in [[Patient Recovery|patient recovery]]. 
===Monitored Plan Activities===
===Patient Adherence=== 
* Medication Adherence
* Activity levels
* other patient behaviors, etc.
===Patient Behavior===
* Patient Activation (Understand condition, Capable of treating self, etc.)
* Technology  Use - have appropriate technology (i.e., wifi Blood pressure cuff), understand how to use it  
===Condition Monitoring===
* Physical Condition - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc. 
* Mental Health Conditions 
* 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)
===Plan Effectiveness Monitoring===
* Medication efficacy (effectiveness, interactions, adverse events), 
* Treatments, procedures, tests, etc. 
* Activities, 
* Recovery team, 
* Protocols
* Appropriateness of Recovery Goals
===Triggers===
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)
===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
* How - phone calls, text message, alerts
* When - notification time frame
* What - is the action?
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

==[[Care Team Determinants|Care Team]]==
[[Recovery Team Factors|Recovery team factors]] are elements of the [[Recovery Management Factors|recovery management factors]] in [[Patient Recovery|patient recovery]]. 
===Clinical Providers===
These are licensed professionals.
* Physicians
* Physician Assistants, Nurse Practitioners
* Pharmacists
* Therapists (Speech, Physical, Occupational}
* Behavior Health (Psychologist, Psychiatrist)
* Nurse (Care Manager)
* Dietitian
* Education Providers (Clinical)

===Support (Social and Behavioral) Providers===
* Care givers (Family or fried)
* Recovery Navigator (patient navigator)
* Recovery Coaches (included MSW Social Workers and Health Coaches)
* Education (Non-Clinical)
* Technical Support and technicians

===Community (Basic Needs) Providers===
* Financial Counseling
* Meals Delivery (Meals on Wheels)
* Transportation Assistance
* Programs (Smoking Cessation, Weight Loss, Alcoholics Anonymous)
* Delivery Services
* Transportation Services 
* Other Services (handy man, plumber, etc.)
* Community Health Services (Community Health Centers, free flu shots, etc.)
* Convenient Care (Minute Clinics, 24 hour services)