Difference between revisions of "Patient Recovery Factors"

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Revision as of 13:26, 10 March 2014

Patient - About

Description 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 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

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

• 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