Patient Recovery Factors

Clinical

These are the Clinical Factors that are a component of the Patient Recovery Factors.

Clinical Conditions

Behavioral Health

• Addictions
• Behavioral Disorders (depression, anxiety disorders, schizophrenia, bipolar etc.)
• Substance Abuse

Comorbidities

• Alzheimer's disease
• Arthritis
• Asthma
• Cancer
• COPD
• Diabetes
• Congestive Heart Failure
• High Blood Pressure
• High Cholesterol
• Obesity
• Osteoporosis
• Stroke

Designations

• Long Term Institutional Status (LTI Status)

Immunizations

• Flu
• Tetanus

Impairments

• Cognitive Impairments (Delirium "confused state", Dementia)
• Developmental Challenges (Autism)
• 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

Microbiome

• Proteome, viruses

Physiological Metrics

• Blood glucose level
• Blood pressure
• Cholesterol level (HDL, LDL, etc)
• Heart rate

Problem lists

• Chest Pain
• Shortness of Breath
• Abdominal pain
• Headache
• Fever
• upper respiratory tract infection
• sprains
• fractures
• wounds
• asthma
• Rash of skin infection

Functional Conditions

Basic Physical

The ten variables addressed in the Barthel scale are:

• presence or absence of fecal incontinence
• presence or absence of urinary incontinence
• help needed with grooming
• help needed with toilet use
• help needed with feeding
• help needed with transfers (e.g. from chair to bed)
• help needed with walking
• help needed with dressing
• help needed with climbing stairs
• help needed with bathing

Basic Life Activities

• Clean home or setting
• Drive
• Laundry
• Prepare food and/or cook
• Shopping (Food, Medicines, necessities, etc.)
• Use Public Transportation,

Logistic Capabilities

• Walk - able to walk, ride in car, ride bus or taxi
• Assisted Walking - walker, cane
• Wheelchair - Travel via 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

• Volunteer, watch grand kids soccer games, etc.
• Golf, weekly lunches with friends, etc.

Mental

Not prevented from working, pursuing passion and functional activities because of mental health challenges

• Fear, confidence in certain situations, etc.

Social and Behavioral

These are the Social and Behavioral Factors which are a component of the Patient Recovery Factors.

Social and Behavioral Factors

Patient - About

This is about how people can relate to the patient.

About

• Narrative/Story
• Photos
• Language Speaking and literacy

Family & Friends

• Marital Status
• Family Members - Their regular interaction, role in care or monitoring, where they live in proximate
• Friends - Their regular interaction, role in care or monitoring, where they live in proximate
• Photos
• Support received from family and friends

Career

• Education Level
• Job History

Passions/Goals

• Sports Teams, Television, reading, social media
• Physical Activities - Walking, shopping, etc.

Stress Factors

• Recent Stressful Events
• Ongoing Stressful Challenges
• Potential Stressful Events

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)

Patient Lifestyle

Activities

• Sports Participation (Golf)
• Sporting Events (enjoy race track, kids sporting events, etc.)
• Television (Watch Baseball, Drama series, News - Favorite programs)
• Social Activities (Social Organizations, frequent bars, etc.)
• Family Activities (dinners, youth sports)
• Travel
• Hobbies
• Home maintenance
• Other Sedentary Activities (Read, knit,etc.)

Volunteering

• Youth Coaching
• Social Service

Care Giver Roles

• Kids, parents, friends

Home

• Snowbird (summers in the North, winters in the South)

Patient Behavior

Physical Activity

• Exercise and Activity Levels
• Transportation (Always walks, always drive, always buses or subways)
• Work (seditary

Nutrition

• Diet and Nutrition
• Nutrition (Fast Food, Take Out, Home cooked meals)

Social Interactions

• Engagement with others
• Engagement with Caregivers, others
• Organized Communities - like PatientsLikeMe
• Socially Isolated

Adverse Behaviors

• Adverse Behaviors (use of alcohol, drugs, gambling, unprotected sex, smoking)

Sentiment

• Upbeat, depressed

Patient Preferences

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

Patient Activation

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

Intervention Activation

• Know when to ask for help
• Comfortable asking for help
• Know who to ask for help

Patient Technology Adoption

This could be for the patient or a patient authorized care giver.

Device Aptitude

• Use of remote monitoring devices (Blood Pressure cuff)
• Use of remote diagnostic devices (ecg app)
• Use of tablet, computer or smartphone

Technology Aptitude

• Internet and Online Usage
• Education Videos
• Patient Portal Usage

Online Personal Health Record

• Online Electronic Health Record
• Access Authorization (Recovery Team access)
• Patient Input History (Patient answer questions or inputs data into Personal Health Record)

Available Technology

• Broadband Internet
• Wifi Router
• Computer
• Smartphone or Tablet
• Remote Monitoring Devices (Blood pressure cuff, blood glucose monitoring)
• Remote Diagnostic Devices (ECG app)

Basic Needs Factors

Patients that have basic needs that are not being addressed will not respond as well to treatments. 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)

Socioeconomic Status

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, Medicare, Medicaid, VA, etc.)
• Deductibles, Co-payments, monthly premiums

Socioeconomic - History

• Credit Rating & History

Physical Environment & Setting

Home

• Location (proximity to services)
• Heat and Air conditioner
• Mould (Asthma), Throw rugs (recent hip replacements)
• Household members (disruptive 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)

Neighborhood

• Safety (for walks)
• Supportive (neighbors friendly)
• Quiet at Night (able to get restful sleep)
• Transportation Access

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, Mould)
• 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
• Halfway House - after recent prison term
• Victim Shelters - domestic and sexual violence, disaster relief

Access & Logistic

Necessities Access

(via delivery or going to the store)

• Medicines
• Food (via delivery or going to the store)
• Other

Transportation

• Physician Offices
• 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)

Recovery Management Factors

Recovery Team

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)

Recovery Plan

Discovery

• Clinical Consults
• Qualified Option Development
• Testing

Treatments

• Medicine
• Procedures
• Surgery
• Therapies (Occupational Therapy, Speech, Physical Therapy)

Activities

• Nutrition
• Education

Recovery Monitoring

Activities Monitoring

• Track Recovery Plan to ensure activities, treatments are on track

Medication Monitoring

• Adverse Medication Events
• Prescriptions Filled
• Medication Adherence
• Medication Effectiveness
• Medication Interactions

Medication Monitoring Method

• Daily Calls
• Patient checks box or inputs data
• Passive sensor (wifi enabled pill boxes or caps)

Physiological Metrics Monitoring

• Blood Pressure

Recovery Reviews

• Status of Surgeries, Procedures, Tests, Therapies, etc.
• Effectiveness or Treatments and Activities
• Effectiveness of recovery team
• Effectiveness of Protocols
• Appropriateness of Recovery Goals

Recovery Protocols

Triggers

Triggers Requiring Notifications

• Patient Concern
• Monitoring Alert - Medication adherence, blood pressure reading, etc.
• 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 - phone calls, text message, alerts
• When - notification time frame

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 Golas, Plan, Monitoring and Protocols

Escalation

• What - gets escalated
• Who - escalates it (nurse, patient) and 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