Difference between revisions of "Patient Recovery Framework"
From PatientRecovery
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| + | To ensure [[Patient Recovery|patient recovery]] and desired overall patient outcomes, an entire [[Patient Recovery Framework|patient recovery framework]] must be developed around the patient. It must be tailored to the specific patient and their desires and needs. | ||
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==Recovery Assessments/Intake== | ==Recovery Assessments/Intake== | ||
Remote or point of service by RN, Social Worker, Recovery Navigator | Remote or point of service by RN, Social Worker, Recovery Navigator | ||
Revision as of 06:40, 28 April 2015
To ensure patient recovery and desired overall patient outcomes, an entire patient recovery framework must be developed around the patient. It must be tailored to the specific patient and their desires and needs.
Contents
Recovery Assessments/Intake
Remote or point of service by RN, Social Worker, Recovery Navigator
Recovery Education
Remote or onsite
- Clinical Condition - Personal Care, Understanding Conditions
- Lifestyle Impact - Lifestyle impact that is permanent or during the recovery process
- Treatment Options - Surgery, therapy and care options like medications, palliative care. Decision aids.
- Patient Preference Options - Advanced Directives, authorization of access, advanced beneficiary options, end of life, provider preferences
Recovery Planning
Development of a recovery plan
- Provider Planning Services - CMS has new care transition reimbursement
- Recovery Planning Team - Physician, Social Worker, Recovery Navigator
“Qualified Option” Development
- Treatment Options - With impact – cost, risk, functional, etc.
- Setting Options - With impact – cost, risk, quality of life
Patient Preferences
Living Will
- Advanced Patient Directives My Directives offers a free online, HIPAA compliant service
Recovery Monitoring
- Physiological, Conditions, Behavioral metrics
- Treatment effectiveness
- Intervention protocols
- Technology setup (wifi, LTE, etc.)
- Personal Emergency Response Systems (PERS)- A single button (i.e., "I've fallen… and I can't get up!" – LifeCall)
Technology Framework
- Analytics
- Digital Health Communications Platform
- Mobile/Digital Enabled Apps, Devices and Services
- Personal Health Record
- Physician eVisits
Recovery Management
Remote or onsite
- Education
- First level triage, escalate as required
- 24 x 7 support
Patient Programs
- Intensive
- Episode
- Chronic Care
- Palliative Care/End of Life
- Care Gaps
- Schedule Appointments and rides to services
- Get services, Rx filled, etc.
- Physician, Social Worker, Recovery Navigator
Technology Support
- Remote – troubleshooting, education, training
- Onsite – troubleshooting, education and training
On-site Setting Support
- Onsite Assessments (throw rugs for hip/knee, mold – asthma/COPD, etc.),
- Technology setup (wifi, LTE, etc.)
- Training/Education on use of equipment, taking care of a wound
Recovery Treatment
Surgeries
Procedures & Tests
Medicine
Therapies
Other Treatments
Recovery Activities
Socioeconomic Status
- Insurance Coverage - apply for Medicaid, petition for coverage of treatment
- Employment - Get a new job or help getting back to work
- Education - for new skills or career
Physician Environment & Setting
- Home Remodeling
- Housing Applications - Assisted Living Center, Homeless shelter, adult day care
Patient Preferences
- Establish Patient Preferences
- Recovery Goals
- Recovery Team
- Recovery Plan
- Recovery Monitoring
- Recovery Protocol
Patient Technology Adoption
- Purchase of devices
- Establish Personal Health Record
