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| − | ==Patient - About==
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| − | This is about how people can relate to the patient.
| + | |
| − | ===About===
| + | |
| − | * Narrative/Story
| + | |
| − | * Photos
| + | |
| − | * Language Speaking and literacy
| + | |
| − | | + | |
| − | ===Family & Friends===
| + | |
| − | * Marital Status
| + | |
| − | * Family Members - Their regular interaction, role in care or monitoring, where they live in proximate
| + | |
| − | * Friends - Their regular interaction, role in care or monitoring, where they live in proximate
| + | |
| − | * Photos
| + | |
| − | * Support received from family and friends
| + | |
| − | | + | |
| − | ===Career===
| + | |
| − | * Education Level
| + | |
| − | * Job History
| + | |
| − | ===Passions/Goals===
| + | |
| − | * Sports Teams, Television, reading, social media
| + | |
| − | * Physical Activities - Walking, shopping, etc.
| + | |
| − | ===Recent Stressful Events===
| + | |
| − | * Accident or Major Injury
| + | |
| − | * Divorce
| + | |
| − | * Death of Spouse or Loved one
| + | |
| − | * Job Loss
| + | |
| − | * Diagnosis of Serious Illness
| + | |
| − | * Criminal Event
| + | |
| − | ===Ongoing Stressful Challenges===
| + | |
| − | * Caregiver for family member in need
| + | |
| − | * Domestic Violence or Abuse (Intimate Partner Violence)
| + | |
| − | * Loneliness
| + | |
| − | * Homelessness
| + | |
| − | * Troubled Family Member
| + | |
| − | * Debt beyond means to repay
| + | |
| − | ===Potential Stressful Events===
| + | |
| − | * Retirement
| + | |
| − | * Move to new home (city, away from comforts or people)
| + | |
| − | * Marriage
| + | |
| − | | + | |
| − | ==Patient Lifestyle and Behavior==
| + | |
| − | ===Behavior===
| + | |
| − | * Exercise and Activity Levels
| + | |
| − | * Diet and Nutrition
| + | |
| − | * Engagement with others
| + | |
| − | * Sentiment (Upbeat, depressed)
| + | |
| − | * Adverse Behaviors (use of alcohol, drugs, gambling, unprotected sex, smoking)
| + | |
| − | * Nutrition (Fast Food, Take Out, Home cooked meals)
| + | |
| − | * Transportation (Always walks, always drive, always buses or subways)
| + | |
| − | ===Lifestyle===
| + | |
| − | * Activities (Golf, Watch Baseball on TV, enjoy race track)
| + | |
| − | * Snowbird (summers in the North, winters in the South)
| + | |
| − | * Social Activities (Social Organizations, frequent bars, etc.)
| + | |
| − | * Work (Night Shifts, lift heavy boxes)
| + | |
| − | | + | |
| − | ===Social Interactions===
| + | |
| − | * Engagement with Caregivers, others
| + | |
| − | * Organized Communities - like [http://www.patientslikeme.com/ '''PatientsLikeMe''']
| + | |
| − | * Socially Isolated
| + | |
| − | | + | |
| − | ==Patient Preferences==
| + | |
| − | ===Authorizations===
| + | |
| − | * Privacy and HIPAA
| + | |
| − | * Advanced Beneficiary Notice
| + | |
| − | * Recovery Team Access to Electronic Medical Records
| + | |
| − | ===Living Will===
| + | |
| − | * Advanced Patient Directives
| + | |
| − | ===Treatment Preferences===
| + | |
| − | * Home Based
| + | |
| − | * Recovery Team
| + | |
| − | * Technology Use
| + | |
| − | * Palliative Care and End of Life preferences
| + | |
| − | | + | |
| − | ==Patient IT Adoption==
| + | |
| − | This could be for the patient or a patient authorized care giver.
| + | |
| − | ===Device Aptitude===
| + | |
| − | * Use of remote monitoring devices (Blood Pressure cuff)
| + | |
| − | * Use of remote diagnostic devices (ecg app)
| + | |
| − | * Use of tablet, computer or smartphone
| + | |
| − | ===Technology Aptitude===
| + | |
| − | * Internet and Online Usage
| + | |
| − | * Education Videos
| + | |
| − | * Patient Portal Usage
| + | |
| − | ===Online Personal Health Record===
| + | |
| − | * Online Electronic Health Record
| + | |
| − | * Access Authorization (Recovery Team access)
| + | |
| − | * Patient Input History (Patient answer questions or inputs data into Personal Health Record)
| + | |
| − | ===Available Technology===
| + | |
| − | * Broadband Internet
| + | |
| − | * Wifi Router
| + | |
| − | * Computer
| + | |
| − | * Smartphone or Tablet
| + | |
| − | * Remote Monitoring Devices (Blood pressure cuff, blood glucose monitoring)
| + | |
| − | * Remote Diagnostic Devices (ECG app)
| + | |
| − | | + | |
| − | ==Clinical Condition==
| + | |
| − | ===Allergies & Adverse Drug Reactions===
| + | |
| − | ===Behavioral Health===
| + | |
| − | * Addictions
| + | |
| − | * Behavioral Disorders (depression, anxiety disorders, schizophrenia, bipolar etc.)
| + | |
| − | * Substance Abuse
| + | |
| − | | + | |
| − | ===Comorbidities===
| + | |
| − | * Alzheimer's disease
| + | |
| − | * Arthritis
| + | |
| − | * Asthma
| + | |
| − | * Cancer
| + | |
| − | * COPD
| + | |
| − | * Diabetes
| + | |
| − | * Congestive Heart Failure
| + | |
| − | * High Blood Pressure
| + | |
| − | * High Cholesterol
| + | |
| − | * Obesity
| + | |
| − | * Osteoporosis
| + | |
| − | * Stroke
| + | |
| − | ===[[CMS-HCC Risk Adjustments]]===
| + | |
| − | ===Designations===
| + | |
| − | * Long Term Institutional Status (LTI Status)
| + | |
| − | ===Genome (DNA)===
| + | |
| − | ===Immunizations===
| + | |
| − | * Flu
| + | |
| − | * Tetanus
| + | |
| − | ===Impairments===
| + | |
| − | * Cognitive Impairments (Delirium "confused state", Dementia)
| + | |
| − | * Developmental Challenges (Autism)
| + | |
| − | * Physical Impairments (Use of limbs, arthritis, amputation, birth defects, Epilepsy)
| + | |
| − | * Sensory Impairments (Blind or Visually Impaired, Deaf or Hard of Hearing, loss of taste and smell)
| + | |
| − | ===Medical History===
| + | |
| − | * Adverse events
| + | |
| − | * Family Medical History
| + | |
| − | * Medical Conditions
| + | |
| − | * Surgeries
| + | |
| − | | + | |
| − | ===Microbiome===
| + | |
| − | * Proteome, viruses
| + | |
| − | ===Pain===
| + | |
| − | ===Physiological Metrics===
| + | |
| − | * Blood glucose level
| + | |
| − | * Blood pressure
| + | |
| − | * Cholesterol level (HDL, LDL, etc)
| + | |
| − | * Heart rate
| + | |
| − | ===Problem lists===
| + | |
| − | * Chest Pain
| + | |
| − | * Shortness of Breath
| + | |
| − | * Abdominal pain
| + | |
| − | * Headache
| + | |
| − | * Fever
| + | |
| − | * upper respiratory tract infection
| + | |
| − | * sprains
| + | |
| − | * fractures
| + | |
| − | * wounds
| + | |
| − | * asthma
| + | |
| − | * Rash of skin infection
| + | |
| − | | + | |
| − | ===Wounds===
| + | |
| − | | + | |
| − | ==Functional Condition==
| + | |
| − | ===Basic Physical===
| + | |
| − | The ten variables addressed in the [http://en.wikipedia.org/wiki/Barthel_scale Barthel scale are:
| + | |
| − | * presence or absence of fecal incontinence
| + | |
| − | * presence or absence of urinary incontinence
| + | |
| − | * help needed with grooming
| + | |
| − | * help needed with toilet use
| + | |
| − | * help needed with feeding
| + | |
| − | * help needed with transfers (e.g. from chair to bed)
| + | |
| − | * help needed with walking
| + | |
| − | * help needed with dressing
| + | |
| − | * help needed with climbing stairs
| + | |
| − | * help needed with bathing
| + | |
| − | | + | |
| − | ===Basic Life Activities===
| + | |
| − | * Clean home or setting
| + | |
| − | * Drive
| + | |
| − | * Laundry
| + | |
| − | * Prepare food and/or cook
| + | |
| − | * Shopping (Food, Medicines, necessities, etc.)
| + | |
| − | * Use Public Transportation,
| + | |
| − | | + | |
| − | ===Logistic Capabilities===
| + | |
| − | * Walk - able to walk, ride in car, ride bus or taxi
| + | |
| − | * Assisted Walking - walker, cane
| + | |
| − | * Wheelchair - Travel via Wheelchair
| + | |
| − | * Equipment Requirements - Oxygen, heart device, etc.
| + | |
| − | | + | |
| − | ===Work===
| + | |
| − | Physically able to go back to work or enough functional ability to find a new job
| + | |
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| − | ===Passion===
| + | |
| − | Physically able to go back to work or enough functional ability to find a new job
| + | |
| − | * Volunteer, watch grand kids soccer games, etc.
| + | |
| − | * Golf, weekly lunches with friends, etc.
| + | |
| − | ===Mental===
| + | |
| − | Not prevented from working, pursuing passion and functional activities because of mental health challenges
| + | |
| − | * Fear, confidence in certain situations, etc.
| + | |
| − | ===Functional History===
| + | |
| − | | + | |
| − | ==Patient Activation==
| + | |
| − | ===Activation Level===
| + | |
| − | * [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - understands conditions, understands treatment, understand how to care for conditions, understands how to manage symptoms
| + | |
| − | * Activation History
| + | |
| − | ===Condition Management Aptitude===
| + | |
| − | * Diabetic monitoring glucose and injecting insulin
| + | |
| − | * Self-care
| + | |
| − | ===Education===
| + | |
| − | * Diagnosis
| + | |
| − | * Prognosis
| + | |
| − | * Treatments
| + | |
| − | * Understand Options and onboard with the treatment plan
| + | |
| − | ===Treatment Adherence===
| + | |
| − | * Medication Adherence
| + | |
| − | * Nutrition
| + | |
| − | * Therapy, Physician Visits
| + | |
| − | * Recommended Activity levels
| + | |
| − | ===Intervention Protocols===
| + | |
| − | * Know when to ask for help
| + | |
| − | * Ask for help
| + | |
| − | | + | |
| − | ==Socioeconomic Status==
| + | |
| − | ===Financial Health===
| + | |
| − | * Income
| + | |
| − | * Wealth
| + | |
| − | * Patient Contributions Capabilities
| + | |
| − | * Financial Constraints (Debt, family commitments) -
| + | |
| − | ===Career===
| + | |
| − | * Sick Days/Leave Availability
| + | |
| − | * Education
| + | |
| − | * Occupation
| + | |
| − | ===Medical Insurance Status===
| + | |
| − | * Employer plan, Medicare, Medicaid, VA, etc.)
| + | |
| − | ===Socioeconomic - History===
| + | |
| − | * Credit Rating & History
| + | |
| − | | + | |
| − | ==Physical Environment & Setting==
| + | |
| − | ===Home===
| + | |
| − | * Location (proximity to services)
| + | |
| − | * Heat and Air conditioner
| + | |
| − | * Mould (Asthma), Throw rugs (recent hip replacements)
| + | |
| − | * Household members (disruptive family member)
| + | |
| − | * Accessibility (Wheel Chair accessible)
| + | |
| − | * Therapy Equipment (Oxygen equipment)
| + | |
| − | * Passive Sensors (wifi enabled weight scale, blue tooth enabled blood pressure cuff)
| + | |
| − | * Internet connection - wifi router
| + | |
| − | ===Neighborhood===
| + | |
| − | * Safety (for walks)
| + | |
| − | * Supportive (neighbors friendly)
| + | |
| − | * Quiet at Night (able to get restful sleep)
| + | |
| − | * Transportation Access
| + | |
| − | ===Facility - Supportive===
| + | |
| − | * Facility type (Nursing home, senior living center, etc.)
| + | |
| − | * Onsite staff (match needs of patients)
| + | |
| − | * Onsite resources (food, outdoors, etc.)
| + | |
| − | * Accessible (Wheel Chair ramps)
| + | |
| − | * Safety (Safety Bathrooms, smoke alarms)
| + | |
| − | * Environmental (Heat, A/C, Mould)
| + | |
| − | * Therapy Equipment (Oxygen equipment)
| + | |
| − | * Passive Sensors (wifi enabled weight scale, blue tooth enabled blood pressure cuff)
| + | |
| − | * Internet connection - wifi router
| + | |
| − | ===Support Team Onsite===
| + | |
| − | * Skilled Nursing
| + | |
| − | * Family Member
| + | |
| − | ===Temporary Housing===
| + | |
| − | * Homelessness
| + | |
| − | * Homeless Shelters
| + | |
| − | * Halfway House - after recent prison term
| + | |
| − | * Victim Shelters - domestic and sexual violence, disaster relief
| + | |
| − | | + | |
| − | | + | |
| − | | + | |
| − | ==Access & Logistic==
| + | |
| − | ===Necessities Access===
| + | |
| − | (via delivery or going to the store)
| + | |
| − | * Medicines
| + | |
| − | * Food (via delivery or going to the store)
| + | |
| − | * Other
| + | |
| − | ===Transportation===
| + | |
| − | * Physician Offices
| + | |
| − | * Special Transportation Needs (Wheel Chair Vehicle)
| + | |
| − | ===Clinical Services Access===
| + | |
| − | * Same day access to Physicians
| + | |
| − | * Nights & Weekend Access to providers
| + | |
| − | * Clinical Care in area, region (i.e., dialysis)
| + | |
| − | | + | |
| − | | + | |
| − | ==Recovery Team==
| + | |
| − | ===Clinical Providers===
| + | |
| − | These are licensed professionals.
| + | |
| − | * Physicians
| + | |
| − | * Physician Assistants, Nurse Practitioners
| + | |
| − | * Pharmacists
| + | |
| − | * Therapists (Speech, Physical, Occupational}
| + | |
| − | * Behavior Health (Psychologist, Psychiatrist)
| + | |
| − | * Nurse (Care Manager)
| + | |
| − | * Dietition
| + | |
| − | | + | |
| − | ===Support (Social) Providers===
| + | |
| − | * Care givers (Family or fried)
| + | |
| − | * Recovery Navigator (patient navigator)
| + | |
| − | * Recovery Coaches (included MSW Social Workers) and Health Coaches
| + | |
| − | * Technical Support and technicians
| + | |
| − | * Delivery Services
| + | |
| − | * Transportation Services
| + | |
| − | * Other Services (handy man, plumber, etc.)
| + | |
| − | | + | |
| − | ===Community (Basic Needs) Providers===
| + | |
| − | * Financial Counseling
| + | |
| − | * Meals Delivery (Meals on Wheels)
| + | |
| − | * Transportation Assistance
| + | |
| − | * Programs (Smoking Cessation, Weight Loss, Alcoholics Anonymous)
| + | |
| − | | + | |
| − | ===Community Health Services===
| + | |
| − | * Community Health Centers
| + | |
| − | * Community Health Services (free flu shots)
| + | |
| − | * Convenient Care (Minute Clinics, 24 hour services)
| + | |
| − | | + | |
| − | ==Recovery Goals==
| + | |
| − | ===Clinical Condition===
| + | |
| − | ===Functional Condition===
| + | |
| − | ===Patient - Activation, Behavior & Lifestyle===
| + | |
| − | ===Physical Environment & Setting===
| + | |
| − | | + | |
| − | ==Recovery Plan==
| + | |
| − | ===Activities===
| + | |
| − | * Nutrition
| + | |
| − | * Education
| + | |
| − | ===Discovery===
| + | |
| − | * Clinical Consults
| + | |
| − | * Qualified Option Development
| + | |
| − | * Testing
| + | |
| − | | + | |
| − | ===Treatments===
| + | |
| − | * Medicine
| + | |
| − | * Procedures
| + | |
| − | * Surgery
| + | |
| − | * Therapies (Occupational Therapy, Speech, Physical Therapy)
| + | |
| − | | + | |
| − | ==Recovery Monitoring==
| + | |
| − | ===Activities Monitoring===
| + | |
| − | * Track Recovery Plan to ensure activities, treatments are on track
| + | |
| − | ===Medicine Monitoring===
| + | |
| − | * Adverse Medication Events
| + | |
| − | * Prescriptions Filled
| + | |
| − | * Medication Adherence
| + | |
| − | * Medication Effectiveness
| + | |
| − | * Medication Interactions
| + | |
| − | ===Medicine Monitoring Method===
| + | |
| − | * Daily Calls
| + | |
| − | * Patient checks box or inputs data
| + | |
| − | * Passive sensor (wifi enabled pill boxes or caps)
| + | |
| − | ===Physiological Metrics===
| + | |
| − | * Blood Pressure
| + | |
| − | ===Treatment Monitoring===
| + | |
| − | * Surgeries, Procedures, Tests, Therapies, etc.
| + | |
| − | | + | |
| − | ==Recovery Management==
| + | |
| − | ===Patient Protocols===
| + | |
| − | * Patient Triggers
| + | |
| − | * Patient Actions
| + | |
| − | * Patient Escalation
| + | |
| − | ===Medicine Monitoring Protocol===
| + | |
| − | * Notification Protocol Triggers
| + | |
| − | * Notification Protocol Actions (Phone Calls, text message, video conference, physical visit)
| + | |
| − | * Notification Protocol People (Patient, Care Giver, Recovery Navigator, Care Manager)
| + | |
| − | * Escalation Protocol Triggers
| + | |
| − | * Escalation Protocol Actions
| + | |
| − | * Escalation Protocol People (Physician, 911)
| + | |
| − | ===Recovery Navigation===
| + | |
