Determinants

Patient Determinants are factors that can decisively affect patient well-being and patient recovery.

Health

These are the Health Determinants that are that can decisively affect patient well-being and patient recovery.

Physical Conditions

Physical Conditions are elements of the determinants of Patient Well-Being and Patient Recovery. Medicare has developed a model to categorize the Physical Conditions 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
• Comorbidities - chronic disorders (or diseases) that need to be managed. Most comorbidities do not get cured.
• Demographics - Age, Sex, Disabled, Long Term Institutional Status (LTI Designated Status)
• Immunizations - Flu, Tetanus
• Physical Impairments - 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 and Symptom lists - Pressure Ulcers, Pain, asthma, Fever, Fractures, Headache, Rash or skin infection, Shortness of Breath, Sprains, Upper respiratory tract infection, Wounds
• Frailty Index

Mental Health Conditions

Mental Health Conditions are elements of the determinants of Patient Well-Being and Patient Recovery.

• Comorbidities - mental health disorders (or diseases) that need to be managed. Most comorbidities do not get cured.
• Disorders - Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Autism, Bipolar Disorder, Eating Disorder, Depression, Obsessive Compulsive Disorder (OCD), Panic Disorders, Post Traumatic Stress Disorder, Schizophrenia
• History
• Impairments - Cognitive Impairments (Delirium "confused state", Dementia), Developmental

Functional Conditions

Functional Conditions are elements of the determinants of Patient Well-Being and Patient Recovery.

• Activities of Daily Living (ADL’s) or the ten variables in the Barthel scale
• Basic Life Activities or the Instrumental Activities of Daily Living (IADLs) - 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

Genomic Profiles

Genomic Profiles are elements of the determinants of Patient Well-Being and Patient Recovery.

• Human Genome] - complete set of genetic information encoded as DNA sequences within the 23 chromosome pairs. It includes the genomes of tumors, the abnormal mass of tissue from abnormal growth or division of cells.

• Microbiome - the collective genomes of the microorganisms that share our body space. The resident bacteria, viruses (virome) and other microbes with genomes.

• Other Genomic Profiles - Metabolome - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. Proteome - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions. Transcriptome - set of all molecules use to create new cells with genomes.

Behavior

These are the Behavior Determinants that are that can decisively affect patient well-being and patient recovery. The psychology determinants are how behavior and the mind relate to the health, social, socioeconomic, environmental and care management.

Activity

Activity determinants are elements are elements of the behavior determinants that impact patient well-being and patient recovery.

• Physical Activity - Exercise, Activity Levels, Behaviors (Always walks, always drive, always buses or subways, Work (how active), Activities (Sports, Hiking, gardening)
• Sleep
• Nutrition - Diet and Nutrition (Fast Food, Take Out, Home cooked meals)
• Adverse Behaviors - use of alcohol, drugs, gambling, unprotected sex, smoking
• Career/Vocation
• Passions
• Social Interactions - Engagement with others, Caregivers, Organized Communities - like PatientsLikeMe, Socially Isolated, Activities (play cards, go to lunches, Social Organizations, frequent bars), Family Activities (dinners, youth sports)
• Social Activities
• Sedentary Activities - Television (Watch Baseball, Drama series, News - Favorite programs, Other Sedentary Activities (Read, knit,etc.)
• Spectator Activities - sports, entertainment, theater, parade, or other events
• Responsibilities Activities - Care Giver Roles to kids, parents, friends
• Travel Activities - Snowbird (summers in the North, winters in the South),Travel, Visit Family

Resilience (Psychological Fitness)

Resilience determinants are elements of the behavior determinants that impact patient well-being and patient recovery. A patient that is psychologically fit can have a positive effect on patient outcomes.

• Emotional Fitness -positive and negative emotions, optimism, flexible thinking, coping, character strengths
• Social Fitness - trust, friendships, balance between privacy and loneliness
• Family Fitness - trust, friendship, intimacy, supportive dialog, manage conflict, avoid escalation
• Spiritual Fitness - religious and non-religious, what provides purpose and meaning
• Socioeconomic fitness - income, marketable job skills, savings, sources of money,
• Stress Factors - Recent Stressful Events, Ongoing Stressful Challenge, Potential Stressful Events
• Support system
• Sentiment - related to health, social, socioeconomic, environmental and care management.
• Change Acceptance and Determination - Acceptance to change to Behavior, Lifestyle, address Problem (Stress), Patient Activation, Patient Technology Adoption. Determination to make change happen. University of Rhode Island Change Assessment Scale (URICA)(URICA)
• Adverse Childhood Experiences (ACE)

Purpose, Competence & Connections

Purpose, Competence & Connections are elements are elements of the behavior determinants that impact patient well-being and patient recovery.

• Goals
• Purpose & Meaning - Spiritual Fitness, part of something bigger than self, responsibilities
• Connection & Love - Family Fitness, Social Fitness, belonging to and having a role in a family, group of friends or community, having meaningful connections that you believe the other person really understands you.
• Competence & Success - Emotional Fitness, Life Satisfaction, responsibilities
• Passion Engagement - engaging in passions, activities, social, career, religious beliefs, mindfulness, hobbies, etc.
• Perspectives
• Treatment Preferences - Home Based, Recovery Team, Technology Use, Palliative Care and End of Life preferences
• Authorizations - Privacy and HIPAA, Advanced Beneficiary Notice, Recovery Team Access to Electronic Medical Records
• Living Will - Advanced Patient Directives

Social

These are the Social Determinants that are that can decisively affect patient well-being and patient recovery.

Patient (About)

Patient (About) determinants are elements are elements of the social determinants that impact patient well-being and patient recovery.

• About - Narrative/Story, Photos, Language Speaking and literacy
• Marital Status
• Family - List of Family Members and their proximity
• Friends - List of Friends with their proximity
• Career - Education Level, Job History
• Language Speaking and literacy
• Passions/Goals - Sports Teams, Television, reading, social media, Activities - Walking, shopping, etc.
• Perspectives - politics, lifestyle, culture
• Race & Ethnicity
• Religious Beliefs - Religion and religious beliefs

Patient Activation

Patient Activation determinants are elements are elements of the social determinants that impact patient well-being and 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
• Medication Management - management and adherence of oral and injectable medicine
• Intervention Activation - Know when to ask for help, Comfortable asking for help, Know who to ask for help
• Technology Aptitude (patient or authorized care giver) - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email, Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
• 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)
• Technology Usage - Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices (Blood pressure cuff, blood glucose monitoring), Remote Diagnostic Devices (ECG app, Accessing patient history via Blue Button

Support

Support determinants are elements are elements of the social determinants that impact patient well-being and patient recovery.

• Caregiver
• Emotional support - from family and friends, provider
• Physical support
• Influential support - people who the patient trusts to help with decision making

Responsibilities

Responsibilities determinants are elements are elements of the social determinants that impact patient well-being and patient recovery.

• Family - Dependent Children, sick family member
• Caregiver role - for family members or friend
• Community Commitments - that helps other people
• Job - that provides income, health insurance that is critical to support family
• Other Demands - pressing demands such as finish school, sell a house, resolve a legal issue.
• Personal Commitments - go to Church on Sunday, go to granddaughters soccer game
• Legal - criminal, civil, traffic, divorce decree, immigration, etc

Socioeconomic

These are the Socioeconomic Determinants that are that can decisively affect patient well-being and patient recovery.

Income

• Current income and stability
• Job Status - Sick Days/Leave Availability, Occupation
• Educational Attainment - Completed levels of formal education,
• Literacy
• Socioeconomic - History - Credit Rating & History

Financial

• Financial Health - Income, Wealth, Patient Contributions Capabilities, Financial Constraints (Debt, family commitments)
• History - Credit Rating
• Legal - judgments, financial legal obligations

Health Insurance

• Employer Health Insurance, Cobra, etc.
• Medicare, Medicaid, private plan
• Health Plan Terms - Deductibles, co-payments, provider network, etc.
• Potential eligibility for Medicaid, disability or other subsidized insurance program

Environmental

These are the Environmental Determinants that are that can decisively affect patient well-being and patient recovery. 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)

Access & Logistics

Access & logistics factors are elements of the patient environment 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, shopping, activities, 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)

Community

Community factors are elements of the patient environment factors in patient recovery.

• Neighborhood - safe, places to walk, amenities within walking distance,
• Supportive Neighbors - friendly, quiet at night (able to get restful sleep), someone to check in nearby
• Amenities - proximity to groceries, pharmacy, parks, etc.
• Transportation Access
• Social events
• Clinical Care Services

Home

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

• Home - Environmental (Heat, Air conditioner, mold-asthma), Throw rugs (falls, recent hip replacements), safety (banisters, etc.), Household members (disruptive/supportive 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)
• Living Arrangement - living alone, with family, Household members (disruptive/supportive family member), congregate living, etc.
• Private Facility - Apartment, House, Room, etc.
• Institution 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, Mold), 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, friend or family members home, Halfway House (after recent prison term), Victim Shelters (domestic and sexual violence, disaster relief)
• Technology - wifi, broadband internet, cable TV, cell phone, cell phone service

Care Management

These are the Care Management Determinants that are that can decisively affect patient well-being and patient recovery.

Care Decision Making & Goals

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

• Discovery - Clinical Consults, Testing, Qualified Option Development
• Desired - Clinical Condition, Functional Condition, Behavior & Lifestyle

Care Plan

• Discovery - Clinical Consults, Testing
• Decision Making - Qualified Option Development
• Treatments (ABCD Interventions) - Medicine, Procedures, Surgery, Therapies (Occupational Therapy, Speech, Physical Therapy)
• E Interventions
• Activities - Nutrition, Education, quit smoking, etc,
• Care Goals

Care Coordination

Care coordination factors are elements of the care management factors in patient recovery.

• Communication within care team
• Arranging diagnosis, second opinions, procedures, etc.
• Patient Navigation

Care Monitoring & Protocols

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

• Recovery Plan Activities - ensure activities are scheduled, treatments happen, prescriptions filled, Recovery Team performs function, Status of Surgeries, Procedures, Tests, Therapies, etc.
• Patient Adherence - Medication Adherence, activity levels, other patient behaviors, etc.
• Patient Activation - Understand condition, capable of treating self, etc.
• Recovery Factors Monitored - Clinical Condition - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.
• Monitoring Method - Daily Calls, Patient checks box or inputs data, Passive sensors (wifi enabled pill boxes or caps)
• Recovery Plan Effectiveness - Medication efficacy (effectiveness, interactions, adverse events), Effectiveness or Treatments and Activities, Effectiveness of recovery team, Effectiveness of Protocols, Appropriateness of Recovery Goals
• Triggers - Triggers Requiring Notifications - Patient Concern, Monitoring Alert (i.e., Medication adherence, blood pressure reading), 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 are they notified (phone calls, text message, alerts)? When are they notified (time frame)?
• Associated Action - Who takes the action? What is the action? How do they take the action (phone calls, text message, alerts)? When do they take action (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 take action?

Care Team

Recovery team factors are elements of the care 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 friend), 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)