Difference between revisions of "Patient Recovery Framework"

Revision as of 16:32, 10 May 2014

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

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

Recovery Navigation

• 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