Care Management Determinants

These are the Care Management 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.

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. Recovery monitoring factors are elements of the recovery 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

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
• Patient Input
• 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

Associated 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)
• 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

Care 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)