Patient Recovery Factors

Clinical

These are the Clinical Factors that are a component of the Patient Recovery Factors.

Clinical Conditions

Medicare has developed a model to categorize the clinical conditions factors in order to risk risk adjust health insurers that are covering patients. The CMS-HCC Risk Adjustments model adjust for patient demographics (i.e., age, disabled) and disease (i.e., diabetes, congested heart failure).

• Allergies & Adverse Drug Reactions
• Behavioral Health
• Comorbidities - chronic disorders (or diseases) that need to be managed. Most comorbidities do not get cured. Comorbidities include behavioral or mental disorders.
• Demographics - Age, Sex, Disabled, Long Term Institutional Status (LTI Designated Status)
• Genomes - Human Genome], Microbiome (and other resident bacteria), Proteome - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions Metabolites - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. Tumors - abnormal mass of tissue as a result of abnormal growth or division of cells. Viruses - small infectious agent that replicates only inside the living cells of other organisms

• Immunizations - Flu, Tetanus
• Impairments - Cognitive Impairments (Delirium "confused state", Dementia), Developmental (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
• Physiological Metrics - Blood glucose level, Blood pressure, Cholesterol level (HDL, LDL, etc), Heart rate
• Problem lists - Pain, asthma, Fever, Fractures, Headache, Rash or skin infection, Shortness of Breath, Sprains, Upper respiratory tract infection, Wounds

Functional Conditions

Functional Conditions are elements of the clinical factors in patient recovery.

• Basic Physical - The ten variables addressed in the Barthel scale are:
• Basic Life Activities - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
• Required Devices - pacemakers, artificial limb, etc.
• Logistic Capabilities - Walk, Assisted Walking, 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
• Mental - Not prevented from working, pursuing passion and functional activities because of mental health challenges
• Functional History

Social and Behavioral

These are the Social and Behavioral Factors which are a component of the Patient Recovery Factors.

Patient (About)

This is about how to understand and relate to the patient. Patient (About) are elements of the social and behavioral factors in patient recovery.

• About - Narrative/Story, Photos, Language Speaking and literacy
• Family & Friends - Marital Status, Family Members, Friends, (Interaction frequency, proximity, support received and given)
• Support - Support from family and friends, support provided to family and friends
• Career - Education Level, Job History
• Passions/Goals - Sports Teams, Television, reading, social media, Activities - Walking, shopping, etc.
• Stress Factors - Recent Stressful Events, Ongoing Stressful Challenge, Potential Stressful Events
• Perspectives - politics, lifestyle, culture
• Spirituality - Religion and religious beliefs, Perspective

Patient Lifestyle

Patient lifestyle factors are elements of the social and behavioral factors in patient recovery.

• Activities (Physical) - Sports Participation (Golf), Sporting Events (enjoy race track, kids sporting events, etc.), , Social Act, Hobbies, Home maintenance,
• Activities (Social) - play cards, go to lunches, Social Organizations, frequent bars, Family Activities (dinners, youth sports)
• Activities (Sedentary) - Television (Watch Baseball, Drama series, News - Favorite programs, Other Sedentary Activities (Read, knit,etc.)
• Volunteering - Youth Coaching, Social Service
• Care Giver Roles - Kids, parents, friends
• Home - Snowbird (summers in the North, winters in the South),Travel, Visit Family

Patient Behavior

Patient behavior factors are elements of the social and behavioral factors in patient recovery.

• Physical Activity - Exercise, Activity Levels, Transportation (Always walks, always drive, always buses or subways, Work (how active)
• Nutrition - Diet and Nutrition (Fast Food, Take Out, Home cooked meals)
• Social Interactions - Engagement with others, Caregivers, Organized Communities - like PatientsLikeMe, Socially Isolated
• Adverse Behaviors - use of alcohol, drugs, gambling, unprotected sex, smoking
• Sentiment - Upbeat, depressed

Patient Preferences

Patient preferences factors are elements of the social and behavioral factors in patient recovery.

• 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 Activation

Patient activation factors are elements of the social and behavioral factors in patient recovery.

• 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 Activation - Know when to ask for help, Comfortable asking for help, Know who to ask for help

Patient Technology Adoption

This could be for the patient or a patient authorized care giver. Patient technology adoption factors are elements of the social and behavioral factors in patient recovery.

• Device Aptitude - Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
• Technology Aptitude - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email
• Online Personal Health Record - Online Electronic Health Record, Blue Button, 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)

Basic Needs

Patients that have basic needs that are not being addressed will not respond as well to treatments. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy. (See: Improving Clinical Outcomes By Addressing Social And Basic Needs)

These are the Basic Needs Factors that are a component of the Patient Recovery Factors.

Socioeconomic Status

Socioeconomic status factors are elements of the basic needs factors in patient recovery.

Financial Health

• Income
• Wealth
• Patient Contributions Capabilities
• Financial Constraints (Debt, family commitments) -

Job Status

• Sick Days/Leave Availability
• Occupation

Education

• Completed levels of formal education
• Literacy

Medical Insurance Status

• Employer plan, Medicare, Medicaid, VA, etc.)
• Deductibles, Co-payments, monthly premiums

Socioeconomic - History

• Credit Rating & History

Physical Environment & Setting

Physical environment & setting factors are elements of the basic needs factors in patient recovery.

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
• Onsite Care Giver Support (i.e., family member)

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

Temporary Housing

• Homelessness
• Homeless Shelters
• Halfway House - after recent prison term
• Victim Shelters - domestic and sexual violence, disaster relief

Access & Logistics

Access & logistics factors are elements of the basic needs factors in patient recovery.

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 Management

These are the Recovery Management Factors that are a component of the Patient Recovery Factors.

Recovery Team

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

Clinical Providers

These are licensed professionals.

• Physicians
• Physician Assistants, Nurse Practitioners
• Pharmacists
• Therapists (Speech, Physical, Occupational}
• Behavior Health (Psychologist, Psychiatrist)
• Nurse (Care Manager)
• Dietitian
• Education Providers (Clinical)

Support (Social and Behavioral) Providers

• Care givers (Family or fried)
• Recovery Navigator (patient navigator)
• Recovery Coaches (included MSW Social Workers and Health Coaches)
• Education (Non-Clinical)
• Technical Support and technicians

Community (Basic Needs) Providers

• Financial Counseling
• Meals Delivery (Meals on Wheels)
• Transportation Assistance
• Programs (Smoking Cessation, Weight Loss, Alcoholics Anonymous)
• Delivery Services
• Transportation Services
• Other Services (handy man, plumber, etc.)
• Community Health Services (Community Health Centers, free flu shots, etc.)
• Convenient Care (Minute Clinics, 24 hour services)

Recovery Goals

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

Recovery Plan

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

Discovery

• Clinical Consults
• Qualified Option Development
• Testing

Treatments

• Medicine
• Procedures
• Surgery
• Therapies (Occupational Therapy, Speech, Physical Therapy)

Activities

• Nutrition
• Education

Recovery Monitoring

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

Activities Monitoring

• Track Recovery Plan to ensure activities, treatments are on track

Medication Monitoring

• Adverse Medication Events
• Prescriptions Filled
• Medication Adherence
• Medication Effectiveness
• Medication Interactions

Medication Monitoring Method

• Daily Calls
• Patient checks box or inputs data
• Passive sensor (wifi enabled pill boxes or caps)

Physiological Metrics Monitoring

• Blood Pressure

Recovery Reviews

• Status of Surgeries, Procedures, Tests, Therapies, etc.
• Effectiveness or Treatments and Activities
• Effectiveness of recovery team
• Effectiveness of Protocols
• Appropriateness of Recovery Goals

Recovery Protocols

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

Triggers

Triggers Requiring Notifications

• Patient Concern
• Monitoring Alert - Medication adherence, blood pressure reading, etc.
• Patient Dialog
• Clinical Condition
• Emergency
• Transfer Event (i.e., Hospital to home)

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

Action

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

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) and 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