Patient Recovery Framework

To ensure patient recovery and desired overall patient outcomes, an entire patient recovery framework must be developed around the patient. It must be tailored to the specific patient and their desires and needs. A Patient Snapshot provides a summary level picture of the patients recovery process.

Recovery Assessments/Intake

Remote or point of service by RN, Social Worker, Recovery Navigator

Recovery Education

Remote or onsite

• Clinical Condition - Personal Care, Understanding Conditions
• Lifestyle Impact - Lifestyle impact that is permanent or during the recovery process
• Treatment Options - Surgery, therapy and care options like medications, palliative care. Decision aids.
• Patient Preference Options - Advanced Directives, authorization of access, advanced beneficiary options, end of life, provider preferences

Recovery Planning

Development of a recovery plan

• Provider Planning Services - CMS has new care transition reimbursement
• Recovery Planning Team - Physician, Social Worker, Recovery Navigator

“Qualified Option” Development

• Treatment Options - With impact – cost, risk, functional, etc.
• Setting Options - With impact – cost, risk, quality of life

Patient Preferences

Living Will

• Advanced Patient Directives My Directives offers a free online, HIPAA compliant service

Recovery Monitoring

• Physiological, Conditions, Behavioral metrics
• Treatment effectiveness
• Intervention protocols
• Technology setup (wifi, LTE, etc.)
• Personal Emergency Response Systems (PERS)- A single button (i.e., "I've fallen… and I can't get up!" – LifeCall)

Technology Framework

• Analytics
• Digital Health Communications Platform
• Mobile/Digital Enabled Apps, Devices and Services
• Personal Health Record
• Physician eVisits

Recovery Management

Remote or onsite

• Education
• First level triage, escalate as required
• 24 x 7 support

Patient Programs

• Intensive
• Episode
• Chronic Care
• Palliative Care/End of Life
• Care Gaps

Recovery Navigation

• Schedule Appointments and rides to services
• Get services, Rx filled, etc.
• Physician, Social Worker, Recovery Navigator

Technology Support

• Remote – troubleshooting, education, training
• Onsite – troubleshooting, education and training

On-site Setting Support

• Onsite Assessments (throw rugs for hip/knee, mold – asthma/COPD, etc.),
• Technology setup (wifi, LTE, etc.)
• Training/Education on use of equipment, taking care of a wound

Recovery Activities

Socioeconomic Status

• Insurance Coverage - apply for Medicaid, petition for coverage of treatment
• Employment - Get a new job or help getting back to work
• Education - for new skills or career

Physician Environment & Setting

• Home Remodeling
• Housing Applications - Assisted Living Center, Homeless shelter, adult day care

Patient Preferences

• Establish Patient Preferences
• Recovery Goals
• Recovery Team
• Recovery Plan
• Recovery Monitoring
• Recovery Protocol

Patient Technology Adoption

• Purchase of devices
• Establish Personal Health Record