Difference between revisions of "Care Management Determinants"
From PatientRecovery
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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. | 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]]. |
| − | [[Recovery Goals Factors|Recovery goals factors]] are elements of the [[ | + | |
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===Discovery=== | ===Discovery=== | ||
* Clinical Consults | * Clinical Consults | ||
* Qualified Option Development | * Qualified Option Development | ||
* Testing | * 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=== | ===Treatments=== | ||
* Medicine | * Medicine | ||
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* Surgery | * Surgery | ||
* Therapies (Occupational Therapy, Speech, Physical Therapy) | * Therapies (Occupational Therapy, Speech, Physical Therapy) | ||
| − | ===Activities=== | + | ===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 | * Nutrition | ||
* Education | * Education | ||
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===Recovery Navigation=== | ===Recovery Navigation=== | ||
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[[Recovery Monitoring Factors|Recovery monitoring factors]] are elements of the [[Recovery Management Factors|recovery management factors]] in [[Patient Recovery|patient recovery]]. | [[Recovery Monitoring Factors|Recovery monitoring factors]] are elements of the [[Recovery Management Factors|recovery management factors]] in [[Patient Recovery|patient recovery]]. | ||
===Recovery Plan Activities=== | ===Recovery Plan Activities=== | ||
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===Patient Adherence=== | ===Patient Adherence=== | ||
* Medication Adherence | * Medication Adherence | ||
Revision as of 10:16, 5 March 2015
These are the Care Management Determinants that are that can decisively affect patient well-being and patient recovery. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy.
Contents
Care Coordination
Care coordination factors are elements of the care management factors in patient recovery.
- Communication within care team
- Arranging diagnosis, second opinions, procedures, etc.
- Patient Navigation
Care Decision Making & Goals
Recovery goals factors are elements of the care management factors in patient recovery.
Discovery
- Clinical Consults
- Qualified Option Development
- Testing
Desired
- Clinical Condition,
- Functional Condition,
- Behavior & Lifestyle
Care Plan & Treatment
Recovery plan factors are elements of the care management factors in 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
Recovery monitoring factors are elements of the recovery management factors in patient recovery. Recovery monitoring factors are elements of the recovery management factors in patient recovery.
Recovery Plan Activities
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
Recovery protocols factors are elements of the recovery management factors in patient recovery.
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
Recovery team factors are elements of the recovery management factors in 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)
