Care Monitoring & Protocols Factors

Care monitoring & protocols factors are elements of the care management factors in patient recovery.

Recovery 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.

Patient Adherence

• Medication Adherence
• Activity levels
• other patient behaviors, etc.

Patient Activation

• Understand condition
• Capable of treating self, etc.
• Technology - have appropriate technology (i.e., wifi Blood pressure cuff), understand how to use it

Recovery Factors Monitored

• Clinical Condition Factors - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.
• Social and Behavioral Factors
• 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)

Recovery Plan Effectiveness

• Medication efficacy (effectiveness, interactions, adverse events),
• Treatments, procedures, tests, etc.
• Activities,
• Recovery team,
• Protocols
• Appropriateness of Recovery Goals

Recovery protocols factors are elements of the recovery management factors in patient recovery.

Event Triggers

Event 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)

Event 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
• What - is the action?
• How - phone calls, text message, alerts
• When - notification time frame

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