Difference between revisions of "Care Management Determinants"
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* Nutrition | * Nutrition | ||
* Education | * Education | ||
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==[[Recovery Monitoring Factors|Care Monitoring & Protocols]]== | ==[[Recovery Monitoring Factors|Care Monitoring & Protocols]]== | ||
| − | [[Recovery Monitoring Factors| | + | [[Recovery Monitoring Factors|Care Monitoring & Protocols]] are elements of [[Care Management Factors|care management]] in [[Patient Recovery|patient recovery]]. |
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===Monitored Plan Activities=== | ===Monitored Plan Activities=== | ||
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===Patient Adherence=== | ===Patient Adherence=== | ||
* Medication Adherence | * Medication Adherence | ||
* Activity levels | * Activity levels | ||
* other patient behaviors, etc. | * other patient behaviors, etc. | ||
| − | ===Patient Behavior | + | ===Patient Behavior=== |
* Patient Activation (Understand condition, Capable of treating self, etc.) | * 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 | * Technology Use - have appropriate technology (i.e., wifi Blood pressure cuff), understand how to use it | ||
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* Protocols | * Protocols | ||
* Appropriateness of Recovery Goals | * Appropriateness of Recovery Goals | ||
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===Triggers=== | ===Triggers=== | ||
Triggers Requiring Notifications | Triggers Requiring Notifications | ||
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* When - do they escalate based on inaction | * When - do they escalate based on inaction | ||
| − | ==[[ | + | ==[[Recovery Team Factors|Care Team]]== |
| − | [[Recovery Team Factors| | + | [[Recovery Team Factors|Care Team determinants]] are elements of the [[Care Management Factors|care management factors]] in [[Patient Recovery|patient recovery]]. |
===Clinical Providers=== | ===Clinical Providers=== | ||
These are licensed professionals. | These are licensed professionals. | ||
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.
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
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)
