Patient Recovery
How do you define Patient Recovery?
Patient recovery is when a patient successfully transitions from an acute or adverse chronic state to a recovered or stable chronic state.
- Acute State - something that requires immediate skilled clinical care such as an urgent care or emergency room visit, hospital visit or post acute stay (killed Nursing Facility, Inpatient Rehabilitation, Home Health).
- Adverse Chronic - this is a non-urgent condition that needs to be addressed soon to prevent an acute state. It could be high blood sugar, high blood pressure, kidney disease, COPD, or asthma that is not under control.
- Recovered - is when the acute condition and/or symptoms no longer prevents the patient from doing what they should be capable of doing if they were fully recovered. It could be back to work or enjoying grandchildren soccer games.
- Chronic Stable" - is when the chronic conditions such as diabetes (blood sugar), hypertension (blood pressure), COPD (blood oxygen levels) are at the recommended levels and patient can resume activities associated with the desired state.
The patient defines recovery by their quality of life preferences based of what is reasonably possible with their clinical diagnosis and prognosis.
Healthcare System
Isn’t patient recovery what our healthcare system provides?
It is not what we are paying our healthcare system to do. Even though most providers are trying to do it anyway, we only pay them to provide clinical services. Also, these clinical services only represent 20% of the factors in health outcomes according to a study by the University of Wisconsin. Health plans and employers (or public health organizations) are also harbored by an antiquated reimbursement system tied to services rather than outcomes like patient recovery.
The three primary approaches to care delivery, which are based on our current reimbursement system, are aligned to “services” rather than “patient outcomes”:
“Case Management” is not patient recovery – A hospital stay, procedure or physician office visit is a service that needs to be cost effectively managed in a way that benefits a patient. Yet providers must tightly manage to the reimbursement level to remain a going entity just like any other service provider. The hospital and other clinical services providers employ case management & care management, yet this is to cost-effectively manage patient clinical services. Also, most of the time spent by a patient recovering occurs outside the four walls of hospitals or physician offices.
“Utilization Management” is not patient recovery – The most effective health insurance plans ensure patients are getting the right services (Utilization Management) for the right price (negotiated provider network). While utilization management and a quality provider network is the best approach to reduce costs and unnecessary services, it doesn’t necessarily help patient recovery. Health plans are paid to effectively manage health care costs for their customers, not deliver health care. Again, most of the recovery occurs outside of clinical services.
“Population Health” is not patient recovery – While employers, labor unions, public health organization and insurers are truly interested in improving the health of their populations, they are not directly involved in patient recovery. Preventive care (i.e., immunizations, annual screenings, care gaps), wellness programs (weight loss, exercise, nutrition) and public health initiatives (smoking, alcoholism) are important programs to improve the health of people over time, yet they are not designed to deliver patient recovery.
If the three primary approaches to healthcare services “Case Management”, “Utilization Management” and “Population Health” are not patient recovery driven, how do will we get there? We start by developing a system aligned to patient recovery for the people using the most services by leveraging:
