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.

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
• Qualified Option Development
• Testing

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)

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.
• Nutrition
• Education

Care Monitoring & Protocols

Care Monitoring & Protocols are elements of care management in patient recovery.

Patient Adherence

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

Patient Behavior

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

Condition Monitoring

• Physical Condition - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.
• Mental Health Conditions
• 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)

Plan Effectiveness Monitoring

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

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

Care Team determinants 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 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)