Difference between revisions of "Care Management Determinants"

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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.
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 +
==[[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]]==
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[[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
 +
 +
==[[Recovery Team Factors|Care Team]]==
 +
[[Recovery Team Factors|Care Team determinants]] are elements of the [[Care Management Factors|care 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)

Latest revision as of 10:32, 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.

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

Care Monitoring & Protocols

Care Monitoring & Protocols are elements of care management in 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

Care Team determinants are elements of the care 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)
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