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
• 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

Functional Conditions

Functional Conditions are elements of the clinical factors in 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

Genomics are elements of the clinical factors in 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.

• Non-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.

Mental Health

• 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

Psychosocial

These are the Psychosocial 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 psychosocial factors in patient recovery.

• About - Narrative/Story, Photos, Language Speaking and literacy
• Marital Status
• Family & Friends - List of Family Members and 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 factors are elements of the psychosocial 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
• 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

Patient Behavior & Lifestyle

Patient behavior & lifestyle factors are elements of the psychosocial factors in patient recovery.

• Physical Activity - Exercise, Activity Levels, Behaviors (Always walks, always drive, always buses or subways, Work (how active), Activities (Sports, Hiking, gardening)
• Nutrition - Diet and Nutrition (Fast Food, Take Out, Home cooked meals)
• 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)
• Career/Vocation
• Adverse Behaviors - use of alcohol, drugs, gambling, unprotected sex, smoking
• Sentiment - Upbeat, depressed
• Serving Others (Volunteer Youth Coaching, Care Giver Roles to kids, parents, friends)
• Home & Travel - Snowbird (summers in the North, winters in the South),Travel, Visit Family
• Other Activities (Sedentary) - Television (Watch Baseball, Drama series, News - Favorite programs, Other Sedentary Activities (Read, knit,etc.)

Patient Goals & Preferences

Patient preferences factors are elements of the psychosocial 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
• 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)
• Religious Beliefs - Religion and religious beliefs

Patient Resilience & Stress

Patient Resilience & Stress factors are elements of the psychosocial factors in patient recovery.

• Psychologically Fit (emotional fitness, social fitness, family fitness, spiritual fitness)
• Stress Factors - Recent Stressful Events, Ongoing Stressful Challenge, Potential Stressful Events

Patient Influences & Support

Patient Influences & Support Factors are elements of the psychosocial factors in patient recovery.

• Caregiver
• Emotional and Physical Support - from family and friends, provider
• Trust - people who the patient trusts
• Influences - people that influence the patient

Patient Well Being

Patient Well Being Factors are elements of the psychosocial factors in patient recovery.

• Positive emotions
• Engagement
• Relationships - Type of relationship and regular contact with friends, family and other acquaintances
• Meaning and Purpose
• Accomplishment

Patient Environment

These are the Patient Environment Factors that, if not addressed, may delay or prevent 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)

These are the patient environment factors that are a component of the Patient Recovery Factors.

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.

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.

Location - Neighborhood, Safety (for walks), proximity to grocery store, services, Supportive (neighbors friendly, Quiet at Night (able to get restful sleep), Transportation Access

• 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)

Socioeconomic Status

Socioeconomic status factors are elements of the patient environment 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, Cobra, Medicare, Medicaid, VA, etc. (Deductibles, Co-payments, monthly premiums)
• Socioeconomic - History - Credit Rating & History

Care Management

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

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 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 & Treatment

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

• Treatments - Medicine, Procedures, Surgery, Therapies (Occupational Therapy, Speech, Physical Therapy)
• Activities - Nutrition, Education

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)