View source for Old Health Determinants

[Health Determinants]] can decisively affect a patient's overall health and well-being. [[Health Determinants]] include [[barriers]], [[symptoms]] and [[Functional Status|functional status]]. The [http://www.dcoe.mil/Libraries/Documents/Phase_2_IOM_Social_Behavioral_Domains_2014_18951.pdf Institute of Medicine (IOM) recommends] capturing social and behavioral determinants in Electronic Medical Records. [https://www.cdc.gov/nchhstp/socialdeterminants/faq.html CDC defines Determinants of health as factors that contribute to a person's current state of health.] 

==Mission ''Determinants''==
'''Mission''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Mission_.26_Care_Goals_Insight Mission Insight].
* Patient's Life Mission
* Patient's Health Mission
===Care Goals ''Determinants''===
'''Care Goals''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Mission_.26_Care_Goals_Insight Health Mission & Care Goals Insight].
* Patient's Care Goals

==Strategy ''Determinants''==
'''Health Strategy''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Strategy_.26_Care_Planning_Insight Health Strategy & Care Planning Insight]. 
===Care Plan ''Determinants''===
'''Care Goals''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Mission_.26_Care_Goals_Insight Health Mission & Care Goals Insight].
* Medications - [https://en.wikipedia.org/wiki/Polypharmacy Polypharmacy] is patients on 4 or more medicines.
* Procedures and Surgery
* Therapies (Occupational Therapy, Speech, Physical Therapy)
* Activities - Nutrition, Education, quit smoking, etc,
* Performance Measures
** Recovery Plan - Effectiveness of recovery team, Effectiveness of Protocols for response and escalations, Appropriateness of Recovery Goals 
** Medication efficacy (effectiveness, interactions, adverse events), 
** Effectiveness of Treatments and Activities,
===Impacting People Roles & Activites ''Determinants''===
'''Impacting People Roles & Activites''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Disciplines_.26_Resources_Insight Health Disciplines & Resources Insight]. 
* Clinical Providers - These are licensed professionals. Primary Care Physicians, Physician Assistants, Nurse Practitioners, Physician Specialists, 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 friend), Recovery Navigator (patient navigator), Recovery Coaches (included MSW Social Workers and Health Coaches), Education (Non-Clinical), Technical Support and technicians
* Community (Basic Needs) Resources - 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)

===Planned Health Strategy Activities ''Determinants''===
====Medical Interventions ''Determinants''====
'''Medical Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Insight Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* Part A ([https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-costs.html hospital/facility interventions]), 
* Part B ([https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html physician interventions]), 
* Part C ([https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html Medicare Advantage Health Plans]), 
* Part D ([https://www.medicare.gov/part-d/ medication interventions]). 
Most health plans are based on Medicare fee schedules, so they typically reimburse for the same or similar services.

'''Medical Interventions Results Outcomes''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Outcomes_Insight Medical Interventions Outcomes Insight].  
* Testing - Clinical Consults, Lab, Imaging, ECG, etc.
* Qualified Option Development - diagnosis, progonosis and treatment options
* Medical Interventions
* Shared Decision Making - process helps to develop interventions based on care goals.

====Non-Medical Interventions ''Determinants''====
'''Non-Medical Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Insight Non-Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

'''Non-Medical Interventions Results''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Outcomes_Insight Non-Medical Interventions Outcomes Insight].
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

====Activity Changes ''Determinants''====
* Adverse Behaviors

==Impacting Realities==
===Health Conditions ''Determinants''===
'''Health Conditions''' Determinants that can decisively affect a patient's overall health and [http://www.patientwell-being.org/general/what-is-personal-well-being/ well-being]. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Conditions_Insight Health Conditions Insight].
====Physical Conditions ''Determinants''====
'''Physical Conditions''' Determinants can decisively affect a patient's overall health and [http://www.patientwell-being.org/general/what-is-personal-well-being/ well-being].  See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Physical_Conditions_Insight Physical Conditions Insight]. Medicare has developed a model to categorize Physical Conditions in order to risk [http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html '''risk adjust'''] health insurers that are covering patients. The [[CMS-HCC Risk Adjustments]] model adjust for patient demographics (i.e., age, disabled) and disease (i.e., diabetes, congested heart failure). 

* Allergies & Adverse Drug Reactions
* [https://en.wikipedia.org/wiki/Comorbidity Comorbidities] -  chronic disorders (or diseases) that need to be managed. Most comorbidities do not get cured.  
* Demographics - Age, Sex, Disabled, Long Term Institutional Status (LTI Designated Status) 
* [http://www.cdc.gov/vaccines/vpd-vac/vaccines-list.htm Immunizations] - Flu, Tetanus
* Physical Impairments -  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
* Physiological Metrics - Blood glucose level, Blood pressure, Cholesterol level (HDL, LDL, etc), Heart rate
* Problem and Symptom lists - Pressure Ulcers, Pain, asthma, Fever, Fractures, Headache, Rash or skin infection, Shortness of Breath, Sprains, Upper respiratory tract infection, Wounds
* [http://www.biomedcentral.com/1471-2318/14/25 '''Frailty Index''']
* [[CCS Diagnostic Categories]]

====Mental Health Conditions ''Determinants''====
'''Mental Health Conditions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Mental_Health_Conditions_Insight Mental Health Conditions Insight].
* Comorbidities -  mental health disorders (or diseases) that need to be managed. Most comorbidities do not get cured.
* Disorders - Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Autism, Bipolar Disorder, Eating Disorder, Depression, Obsessive Compulsive Disorder (OCD), Panic Disorders, Post Traumatic Stress Disorder, Schizophrenia
* History
* Impairments - Cognitive Impairments (Delirium "confused state", Dementia), Developmental

====Functional Conditions ''Determinants''====
'''Functional Conditions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Functional_Conditions_Insight Functional Conditions Insight].
* [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Activities of Daily Living (ADL’s)'''] or the ten variables in the [http://en.wikipedia.org/wiki/Barthel_scale '''Barthel scale''']
* Basic Life Activities or the [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Instrumental Activities of Daily Living (IADLs)'''] - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
* Required Devices - pacemakers, artificial limb, etc.
* Logistic Capabilities - Walk, Assisted Walking, Wheelchair, Equipment Requirements (Oxygen, heart device, etc.)
* Disabilities and Impairments as defined by the [http://www.dc37.net/about/graphics/factsheetspdf/disability_defined.pdf American Disabilities Act]
* Homebound - unable to travel to physician offices
* 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
* Mental - Not prevented from working, pursuing passion and functional activities because of mental health challenges
* [[Requires Support]] - for ADLs or IADLs
* Functional History

====Genomic Profiles ''Determinants''====
'''Genomic Profiles''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Genomic_Profiles_Insight Genomic Profiles Insight].

* [http://en.wikipedia.org/wiki/Human_genome '''Human Genome''']] - complete set of genetic information encoded as DNA sequences within the 23 chromosome pairs. It includes the genomes of [http://en.wikipedia.org/wiki/Tumor '''tumors'''], the abnormal mass of tissue from abnormal growth or division of cells. 

* [http://en.wikipedia.org/wiki/Microbiome '''Microbiome'''] - the collective genomes of the microorganisms that share our body space. The resident bacteria, viruses ([http://en.wikipedia.org/wiki/Human_virome '''virome''']) and [http://en.wikipedia.org/wiki/Eukaryote '''other microbes with genomes''']. 

* Other Genomic Profiles - [http://en.wikipedia.org/wiki/Metabolome '''Metabolome'''] - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. [http://en.wikipedia.org/wiki/Proteome '''Proteome'''] - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions.  [http://en.wikipedia.org/wiki/Transcriptome '''Transcriptome'''] - set of all molecules use to create new cells with genomes. [https://ghr.nlm.nih.gov/handbook/howgeneswork/epigenome '''epigenome''']  multitude of chemical compounds that have been added to the entirety of one’s DNA (genome) as a way to regulate the activity (expression) of all the genes within the genome. These chemical compounds of the epigenome are not part of the DNA sequence, but are on or attached to DNA (“epi-“ means above in Greek).

===Competencies ''Determinants''===
'''Competencies''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Competencies_Insight Health Competencies Insight].

====Health Literacy ''Determinants''====
Health Literacy Determinants impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Literacy_Insight Health Literacy Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - Undertands why and how to manage their health. These competencies help improve [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Behavior_Determinants Self-Management Behavior].
* Health Risks - understand their health risks and how to manage them
* Health Conditions - understands their health conditions 
* Health Condition Management Knowledge - understands how to manage their health conditions (i.e., Diabetic glucose monitoring and injecting insulin)
* Interventions (Medical and Non-Medical)- understands why the interventions are necessary for overall health.
* Assistance Engagement - Know when to ask for help, Comfortable asking for help, Know who to ask for help
* Education - Diagnosis, Prognosis, Treatments, Understand Options and onboard with the treatment plan

====Self-Management Competencies ''Determinants''====
Self Management Competencies Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Self-Management_Competencies_Insight Self-Management Competency Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - have competencies to manage conditions, interventions (medical or non-medical) and is committed to the treatment. These competencies help improve [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Behavior_Determinants Self-Management Behavior].
* Health Condition Management Competencies - understands how to manage their health conditions (i.e., Diabetic glucose monitoring and injecting insulin)
* Conscientiousness - a desire to do a task well being thorough, careful, or vigilant. 
* Reliable and Organized - as opposed to easy-going and disorderly.
* Intervention (Medical or Non-Medical) Competencies - Medication Adherence, Nutrition, Therapies, Physician Visits, Recommended Activity levels 
* Medication Management Competencies - management and adherence of oral and injectable medicine
* Assistance Engagement - Know when and how to ask for help, Comfortable asking for help, Know who to ask for help
* Technology Competencies (patient or authorized care giver) - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email, Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
* Access Online Personal Health Record - Online Electronic Health Record, Blue Button, Access Authorization (Care Team access), Patient Provided Input History (Patient answer questions or inputs data into Personal Health Record)
* Technology Access - Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices

====Functional Competencies ''Determinants''====
'''Functional Competencies''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Competencies_Insight Competencies Insight]. 
* [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Activities of Daily Living (ADL’s)'''] or the ten variables in the [http://en.wikipedia.org/wiki/Barthel_scale '''Barthel scale''']
* Basic Life Activities or the [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Instrumental Activities of Daily Living (IADLs)'''] - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
* [[Education and Literacy Determinants|Literacy]] - ICD Codes
* Languages - Speaking & Reading
* Technology Usage - Smart Phone, Google, Online Patient Portals

====Education ''Determinants''====
'''Education''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Education_Insight Education Insight]. 
* [[Education and Literacy Determinants|Education]] - ICD Codes
* [[Educational Attainment]] - Completed levels of formal education,
* Vocational Training
* Certifications, Licenses or degrees (diplomas)

===Social ''Determinants''===
'''Social''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Social_Insight Social Insight].

====Patient (About & History) ''Determinants''====
'''Patient (About & History)''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Patient_.28About_.26_History.29_Insight Patient (About & History) Insight].
* About - Narrative/Story, Photos
* [[Marital Status]]
* [[Childhood Events Determinants|Childhood events]] 
* [[Childhood Upbringing Determinants|Childhood upbringing]]
* Military Service
* [[Psychosocial Circumstances Determinants|Psychosocial Circumstances]] 
* Passions/Goals - Sports Teams, Television, reading, social media, Activities - Walking, shopping, etc.
* Sexual Orientation
* [[Race & Ethnicity]]
* Country of Origin/US Born or Non-US Born

====Beliefs ''Determinants''====
'''Beliefs''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Beliefs_Insight Beliefs Insight].
* Health Literacy Beliefs
* Religion and faith
* Perspectives - politics, lifestyle, culture
* Trust and faith in Institutions - Healthcare, Education, Government
* Trust and faith in Physicians, nurses and the medical professions
* Beliefs about impacting people, caregivers, family, friends, care team
* Beliefs in whether the current care plan will work
* Beliefs about current health conditions
* Beliefs about physicial activity, nutrition and sleep
* Beliefs about adverse behavior
* Beliefs about self-management of health

====Determination ''Determinants''====
'''Determination''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Determination_Insight Determination Insight].
* Willingness to change or do something different
* Desire to make change happen
* Eagerness to learn how to improve health
* Desire to improve health
* Detrmination to stick to a plan to achieve the desired outcome
* Desire to make something happen
* Enthusiasm to make something happen
* Personal goals and dreams

====Relationships ''Determinants''====
'''Relationships''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Resilience_Insight Relationships Insight]. A patient with good or functional relationships with the [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Impacting_People_Determinants Impacting People] can have a positive effect on patient outcomes. The [http://wikidreams.org/index.php?title=Relationships relationship type], type and frequency of communication as well as what is recieved from the relationship. 
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Physicians Physicians]
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Care_Team_Determinants Care Team] members
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Caregivers_Determinants Caregivers]
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Family_Members_.26_Friends_Determinants Family & Friends]
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Support_Team_Determinants Support Team]
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Organizations_Determinants Organizations]
* [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Other_Contributors_Determinants Other Contributors]

====Resilience ''Determinants'' - (Psychological Fitness)====
'''Resilience''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Resilience_Insight Resilience Insight]. A patient that is psychologically fit can have a positive effect on patient outcomes. 
* ''Emotional Fitness'' -positive and negative emotions, optimism, flexible thinking, coping, character strengths 
* ''Social Fitness'' - trust, friendships, balance between privacy and loneliness
* ''Family Fitness'' - trust, friendship, intimacy, supportive dialog, manage conflict, avoid escalation
* ''Spiritual Fitness'' - religious and non-religious, what provides purpose and meaning
* ''Socioeconomic fitness'' - income, marketable job skills, savings, sources of money, 
* Stress Factors - Recent Stressful Events, Ongoing Stressful Challenge, Potential Stressful Events
* Optimism and Self-Efficacy - belief in ability to succeed in specific situations or accomplish a task which can play a major role in how one approaches goals, tasks, and challenges.
* Support system
* Sentiment - related to health, social, socioeconomic, environmental and care management [[Health Determinants|determinants]].
* 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 [http://www.umbc.edu/psyc/habits/content/ttm_measures/urica/  '''(URICA)''']
* [http://www.cdc.gov/violenceprevention/acestudy/ '''Adverse Childhood Experiences (ACE)''']
* Adversity Exposure - Violence, verbal abuse, death, poverty, financial stress, depression, anxiety

====Responsibilities ''Determinants''====
'''Responsibilities''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Responsibilities_Insight Responsibilities Insight].
* Family - Dependent Children, sick family member
* Caregiver role - for family members or friend
* Community Commitments - that helps other people
* Employment Income - that provides income, health insurance that is critical to support family
* Other Demands - pressing demands such as finish school, sell a house, resolve a legal issue.
* Personal Commitments - go to Church on Sunday, go to granddaughters soccer game
* Legal Responsibilities - criminal, civil, divorce decree, immigration, etc

====Social Well-Being ''Determinants''====
'''Social Well-Being''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Social_Well-Being_Insight Social Well-Being Insight].
* [[Social Environment Determinants|Social Environment]] 
* Goals
* '''Purpose & Meaning''' - ''Spiritual Fitness'', part of something bigger than self, responsibilities 
* '''Competence & Success''' - ''Emotional Fitness'', Life Satisfaction, responsibilities 
* '''Passion Engagement'''  - engaging in passions, activities, social, career, religious beliefs, mindfulness, hobbies, etc.
* Perspectives
* Dignity - feeling worthy of acceptance, feeling you have something to contribute, you can accomplish things without help
* '''Connection & Love''' - feeling love or feeling meaningful connections that you believe the other person really understands you.
* ''Family'' - a sense of belonging to and having a role in a family, group of friends or community, having meaningful connections that you believe the other person really understands you. 
* '''Friendships''' - people you feel comfortable talking to, spending time with or sharing a passion with
* '''Social Status''' - how we believe we are scene within family, friends, community, work, etc.
* ''Spouse''

====Support ''Determinants''====
'''Support''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Support_Insight Support Insight]. 
* [[Social Support Group Determinants|Social support group]]
* Caregiver
* Emotional support - from family and friends, provider
* Physical support - someone who can be there physically to help
* Influential support - people who the patient trusts to help with decision making

===Socioeconomic ''Determinants''===
'''Socioeconomic''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Socioeconomic_Insight Socioeconomic Insight].
====Can't Afford Treatments ''Determinants''====
'''Can't Afford Treatments''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Can.27t_Afford_Treatments_Insight Can't Afford Treatments Insight]. 
* Delaying medical care
* Not filling prescribtion because of cost
* Not beliveing the treatment cost is worth the value

====Financial ''Determinants''====
'''Financial''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Financial_Insight Financial Insight].
* Credit Rating
* Bankruptcy Threat
* [[Economic Circumstances Determinants|Economic circumstances]] - ICD Codes
* [[Financial Concerns]]
* Financial Health - Income, Wealth, Patient Contributions Capabilities, Financial Constraints (Debt, family commitments)  
* Financial History

====Food Insecurity ''Determinants''====
'''Food Insecurity''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Food_Insecurity_Insight Food Insecurity Insight]. 
* Missed Meals
* Low nutrition food due to cost
* Low nutrition food due to food desert

====Health Insurance ''Determinants''====
'''Health Insurance''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Insurance_Insight Health Insurance Insight].
* Employer Health Insurance, Cobra, etc. 
* Medicare, Medicaid, private plan
* Health Plan Terms - Deductibles, co-payments, provider network, etc.
* Potential eligibility for Medicaid, disability or other subsidized insurance program

====Income & Work ''Determinants''====
'''Income & Work''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Income_.26_Work_Insight Income & Work Insight].
* [[Employment Determinants|Employment challenges]] - ICD Codes
* Employment Flexibility - Sick Days/Leave Availability, Occupation
* [[Employment Level]] - ICD Codes
* [[Employment Status]] - ICD Codes
* [[Household Income]] - ICD Codes
* Income History
* Income Sources
* Income Stability - via employment, retirement or other
* Occupation
* [[Occupational Exposures Determinants|Occupational exposures]] - ICD Codes

====Legal ''Determinants''====
'''Legal''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Legal_Insight Legal Insight]. 
* Financial or Legal judgments
* Legal obligations
* [[Legal or Criminal Determinants|Legal or criminal]] - ICD Codes
* Legal Status - citizen status
* Pending Legal Challenges - criminal, civil, traffice violation, divorce decree, immigration, etc

===Environmental ''Determinants''===
'''Environmental''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Environmental_Insight Environmental Insight]. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy. (See: [http://www.health3-0.com/reimbursement/addressing-social-and-basic-needs/ ''Improving Clinical Outcomes By Addressing Social And Basic Needs''])

====Access & Logistics ''Determinants''====
'''Access & Logistics''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Access_.26_Logistics_Insight  Access & Logistics Insight]. 
* Necessities Access (via delivery or going to the store) - Medicines, Food (via delivery or going to the store), Other
* Public Transportation, pedestrian and bike infrastructure to promote physical activity
* Unsafe pedestrian crossings increase risk of injury
* Transportation - Physician Offices, shopping, activities, 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)

====Communication ''Determinants''====
'''Communication''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Communication_Insight Communication Insight].

The physical form of available communications.
* Phone
* Internet
* Text Messaging
* Mail
* Face-to-face
* Mobile Apps
* Through caregiver

====Community ''Determinants''====
'''Community''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Community_Insight Community Insight]. 
* [[Physical Environment Determinants|Physical environment]]
* Neighborhood - safe, places to walk, amenities within walking distance, 
* Supportive Neighbors - friendly, quiet at night (able to get restful sleep), someone to check in nearby 
* Amenities - proximity to groceries, pharmacy, parks, etc., density of liquor stores can increase use
* Proximity to child care, clinics and jobs 
* Transportation Access
* Social events
* Food deserts - lack of fresh foods
* Clinical Care Services
* Air Quality - pollution may degrade indoor air quality and increase risk of asthma, heart disease and other illnesses
* Crime 
* Noise - from roadways, industry and airports can degrade quality of sleep

====Home ''Determinants''====
'''Home''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Home_Insight Home Insight]. 
* [[Physical Environment Determinants|Physical environment]] - exposure to noise, air pollution, water pollution, soil pollution, radiation, other pollution, inadequate drinking-water supply, tobacco smoke (passive smoking)
* [[Housing Circumstances Determinants|Housing circumstances]] - Homelessness, Inadequate housing (Lack of heating, Restriction of space, Technical defects), Discord with neighbors, lodgers and landlord, Problems related to living in residential institution (Boarding-school resident), problems related to housing and economic circumstances (Foreclosure on loan, Isolated dwelling, Problems with creditors) 
* Housing Costs - affect ability to afford food and other essential basic needs
* Housing Structure - Old Carpet and mold can trigger asthma, Structural problems increase the risk of falls and burns, stairway design can promote exercise, safety amenities (banisters, smoke alarms, etc.), Accessibility (Wheel Chair accessible)
* Home Furnishing - Throw rugs (falls, recent hip replacements) 
* Home - Environmental (Heat, Air conditioner, water, hot water)
* Place to store medications to keep cold
* Exposure to firearms
* Exposure to opioids  
* Household members - disruptive/supportive family member, Onsite Care Giver Support or from family members
* Living Arrangement - living alone, congregate living, etc.
* Private Facility - Apartment, House, Room, etc.
* Institution 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, Mold), 
* Temporary Housing - Homelessness, Homeless Shelters, friend or family members home, Halfway House (after recent prison term), Victim Shelters (domestic and sexual violence, disaster relief)

====Security ''Determinants''====
'''Security''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Security_Insight Security Insight]. 

===Digital Content & Techology ''Determinants''===
'''Digital Content & Technology''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Content_Insight Digital Content & Technology Insight].

====Medical Records Determinants==== 
'''Medical Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Records_Insight Medical Records Insight].
* Comprehensive Medical Record - Ensure one location has combined medical records from multiple providers, such as a Primary Care Physician office. 
* Accurate - Ensure the Medical Record ion accurate
* Preventitive Care - Ensure recommended Home Technology - wifi, broadband internet, cable TV, phone 
* No Care Gaps - Ensure their are no open care gaps (i.e., diabetic, yet no hA1C test in past 6 months
* Diagnosis Codes (ICD-10 Codes)
* Physical and Mental Health Biomarkers - Blood Pressure, HbA1C blood test, cholesterol, Depression, Anxiety, etc.
* [[Symptoms]] 
* [http://www.patientdeterminants.org/index.php?title=Determinants#Functional_Conditions_Determinants Functional Conditions]
* Quality of Life Limitations - [http://www.patientdeterminants.org/index.php?title=Determinants#Activity_Determinants Activity], [http://www.patientdeterminants.org/index.php?title=Determinants#Socioeconomic_Determinants Socioeconomic] and [http://www.patientdeterminants.org/index.php?title=Determinants#Social_Determinants Social]
* Advanced Directives
* Preferences - Authorizations, Living Will, etc.
* [[Medical Interventions]] and [[Non-Medical Interventions]]

====Health Determinants Records==== 
'''Health Determinants Records''' can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Determinants_Records_Insight Health Determinants Records Insight].
* Methods of capturing Health Determinants
* Record of Health Determinants
* Patient Generated Data

====Health Interventions Records Determinants====
'''Health Interventions Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Interventions_Records_Insight Health Interventions Records Insight].
* History of Interventions (Medical and Non-Medical)
* Current Health Interventions

====Health Outcomes Records Determinants====
'''Health Outcomes Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Outcomes_Records_Insight Health Outcomes Records Insight].
* Health Outcomes tied to Health Determinants and Health Interventions
* Current Health Outcome Plans
* History of Health Outcomes
* Patient Reported Outcomes

====Technology & Apps ''Determinants''====
'''Technology & Apps''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Technology_.26_Apps_Insight Technology & Apps Insight]. 
* Apps - mobile, computer applications 
* Durable Medical Equipment - Oxygen equipment, nebulizers, Continuous positive airway pressure (CPAP) devices, single and bi-level, manual and power wheelchairs, scooters, and walkers
* Home Technology - wifi, broadband internet, cable TV, phone 
* Mobile - cell phone, cell phone service
* Passive Sensors (wifi enabled weight scale, blue tooth enabled blood pressure cuff)

==Impacting People ''Determinants''==
'''Impacting People''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#People_Insight People Insight].These are people that may support and/or influence the overall health.  

===Physicians===
* Primary Care Physicians 
* Physician Specialists 
* Advanced Practice Professional (APPs)  - Physician Assistants, Nurse Practitioners,
* Behavior Health (Psychologist, Psychiatrist)

===Care Team ''Determinants''===
'''Care Team''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Team_.26_Resources_Insight Care Team & Resources Insight].
====Credentialed Care Specialists ''Determinants''====
Credentialed Care Specialists providers that could influence health outcomes 
* Pharmacists, 
* Therapists - Physical Therapists (PT) / Occupational Therapists (OT) / Speech Therapists (ST)
* Behavior Health (Psychologist, Psychiatrist), 
* Clinical Social Worker - Licensed Social Workers (LSW) or Medical Social Workers (MSW)
* Nurses (Care Manager) Registered Nurses (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
* Dietitians 
* Clinical Educators Providers
====Credentialed Support Providers ''Determinants''==== 
Credentialed Support (Social and Behavioral) Providers - These are professionals that required some credentialing. 
* Home Health - Certified Nursing Assistants (CNA) / Home Health Aides (HHA)
* Medical Assistants 
* Behavioral Health 
* Patient Navigator - Recovery Navigator 
* Health Coaches - Recovery Coaches 
* Social Workers 
* Legal Counselors
* Home Health

===Caregivers ''Determinants''===
Trusted:
* Family Member 
* Friend

===Family Members & Friends ''Determinants''===
'''Family Members & Friends''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Family_Members_.26_Friends_Insight Family Members & Friends Insight].
For each family member and friend, list their proximity, relationship (cordial, respect, etc.), regularity of social interations  
* '''Family''' - List of Family Members and 
* Friends - List of Friends with their proximity 
* Spouse or Signicant Other
* Parents 
* Siblings
* Children
* In-Laws
* Step-Family 
* Friends - List of Friends with their proximity
* Neighbors

===Support Team ''Determinants''===
'''Support Team''' (Non-Clinically Credentialed) Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Team_.26_Resources_Insight Care Team & Resources Insight].
For each support team memeber, list their proximity, relationship (cordial, respect, etc.), regularity of social interations  
* Educators (i.e., literacy, hobbies, etc.)
* Financial Counselors
* Community Health Workers
* Technical Support - Technical Support and technicians
* Attorneys
* Community Resources Providers (See Community Resources)
* Other Services (handy man, plumber, etc.),

===Organizations ''Determinants''===
'''Organizations''' Determinants can decisively affect a patient's overall health and well-being. These are communities that may support and/or influence the overall health.  

====Healthcare Organizations====
* Retail Pharmacies
* Pharmaceutical 
* Medical Devices
* Hospital 
* Medical Practices
* Health Insurers
* Community Health Centers - free flu shots, etc.
* Convenient Care (Minute Clinics, 24 hour services)

====Government Organizations====
* Town
* County
* State
* Federal 

====Employer====

====Community and Social Services Organizations ====
* Food Banks
* Churches  
* Meals Delivery (Meals on Wheels), 
* Transportation Assistance and Services 
* Programs (Smoking Cessation, 
* Weight Loss, Alcoholics Anonymous), 
* Home Maintenance Services - handy man, plumber, etc.

====Support Resources Organizations====

===Other Contributors ''Determinants''===
'''Other Contributors''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Other_Contributors_Insight Other Contributors Insight]. 
* Manager or Superviosr at Work
* Other Key Contributers 
* Influencers - Teacher
* Volunteers
* Other Resources of Providers

==Impacting Activities ''Determinants''==
'''Impacting Activities''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Behavior_Insight Behavior Insight]. The psychology determinants are how behavior and the mind relate to the health, social, socioeconomic, environmental and care management [[Health Determinants|determinants]].  

===Physical Activities ''Determinants''===
'''Physical Activities''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Exercise
* Activity Levels, 
* Frequency of activity (vs. long duration of sitting)
* Behaviors (Always walks, always drive, always buses or subways) 
* Work (how active), 
* Activities (Sports, Hiking, gardening)

===Social & Passion Activities ''Determinants''===
'''Social & Passion Activities''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Social Interactions - Engagement with others, Caregivers, Organized Communities - like [http://www.patientslikeme.com/ '''PatientsLikeMe'''], 
* Periods of Social Isolation, 
* Social Activities (play cards, go to lunches, Social Organizations, frequent bars), 
* Family Activities (dinners, youth sports)
* Passion Activities -
* Sedentary Activities - Television (Watch Baseball, Drama series, News - Favorite programs, Other Sedentary Activities (Read, knit,etc.) 
* Spectator Activities - sports, entertainment, theater, parade, or other events
* Travel - Visit Family, Friends, Vacation
* Seasonal Travel - Snowbird (summers in the North, winters in the South),

===Nutrition ''Determinants''===
'''Nutrition''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Number and times of meals
* Number and types of snacking
* Nutritional value and amounts of food
* Behaviors - Fast Food, Take Out, Home cooked meals
* Diets and Dieting

===Functional Activities ''Determinants''===
'''Functional Activities''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Education Activities
* Income & Work activities
* Home maintenance
* [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Activities of Daily Living (ADL’s)'''] or the ten variables in the [http://en.wikipedia.org/wiki/Barthel_scale '''Barthel scale''']
* Basic Life Activities or the [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Instrumental Activities of Daily Living (IADLs)'''] - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
* Responsibilities Activities - Care Giver Roles to kids, parents, friends
* Travel Activities - driving to work, store or giving a ride to a family memeber

===Sleep ''Determinants''===
'''Sleep''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Total Hours of sleep each day
* Types of sleep - deep, REM, light, naps
* Number of interruptions
* When sleep occurs

===Stress, Emotions & Meditation ''Determinants''===
'''Stress, Emotions & Meditation''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Adverse_Behaviors_Insight Stress, Emotions & Meditation Behaviors Insight].
* Stress - work, financial, responibilities
* Positive Emotions - love, affection, work satisfaction, appreciative, goal oriented, feeling good from phyical activities, calm
* Negative Emotions - anxiety, depression, poor health, being ignored or taking for grated, constant distrations, unhappy, unfulfilled, angry 
* Meditation

===Adverse Behaviors ''Determinants''===
'''Adverse Behaviors''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Adverse_Behaviors_Insight Adverse Behaviors Insight].
* Alcohol, 
* Drugs, 
* Falls
* Gambling, 
* Unprotected sex, 
* Smoking

===Self-Management Behavior ''Determinants''===
'''Self-Management Behavior''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Self-Management_Behavior_Insight Self-Management Behavior Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - patient's management of interventions (Medical or Non-Medical), conditions, and symptoms based on the patient's [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Competencies_Determinants Self-Management Competencies].
* History of self-management behavior 
* Condition Management Behavior - Diabetic monitoring glucose and injecting insulin, Self-care
* Conscientiousness - behavior of doing a task well, being thorough, careful, and/or vigilant. 
* Reliable and Organized - behavior as opposed to easy-going and disorderly.
* Treatment Adherence Behavior - Medication Adherence, Nutrition, Therapy, Physician Visits, Recommended Activity levels 
* Medication Management - management and adherence of oral and injectable medicine
* Intervention Activation - Know when to ask for help, Comfortable asking for help, Know who to ask for help
* Technology Aptitude (patient or authorized care giver) - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email, Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
* Online Personal Health Record - Online Electronic Health Record, Blue Button, Access Authorization (Recovery Team access), Patient Input History (Patient answer questions or inputs data into Personal Health Record)
* Technology Usage - Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices (Blood pressure cuff, blood glucose monitoring), Remote Diagnostic Devices (ECG app, Accessing patient history via [http://www.healthit.gov/patients-families/blue-button/about-blue-button Blue Button]
===Care Management - Communications ''Determinants''===
'''Care Management Communications''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Management_-_Communications_Insight Care Management - Communications Insight].  
* Patient communication - Who? (with care team), How? (in-person, phone, email, text, apps) Frequency? (i.e., dailly, as-needed)
* Patient Inquiries - who? how? response time?
* Patient Status - Symptoms, Problem Lists, Concerns, Functional Status, risk factors, Quality of Life Opportunity
* Recovery Plan Activities - ensure activities are scheduled, treatments happen, prescriptions filled, Recovery Team performs function, Status of Surgeries, Procedures, Tests, Therapies, etc.  
* Patient Adherence - Monitoring of Medication Adherence, activity levels, other patient behaviors, etc.
* Patient Activation - Understand condition, capable of treating self, etc. 
* Recovery Factors Monitored - Clinical Condition - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.  
* Monitoring Method - Daily Calls, Patient checks box or inputs data, Passive sensors (wifi enabled pill boxes or caps)

===Care Management - Operational ''Determinants''===
'''Care Management - Operational''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Management_-_Operational_Insight Care Management - Operational Insight]. 
* Communication methods within care team - phone, text, portal, etc.
* Arranging diagnosis, second opinions, procedures, etc.
* Patient Navigation
* Triggers - Triggers Requiring Notifications - Patient Concern, Monitoring Alert (i.e., Medication adherence, blood pressure reading), 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 are they notified (phone calls, text message, alerts)? When are they notified (time frame)?
* Associated Action - Who takes the action? What is the action? How do they take the action (phone calls, text message, alerts)? When do they take action (time frame)? 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 take action?

===Health Strategy Activities ''Determinants''===
====Medical Intervention Activities ''Determinants''====
'''Medical Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Insight Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* Part A ([https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-costs.html hospital/facility interventions]), 
* Part B ([https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html physician interventions]), 
* Part C ([https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html Medicare Advantage Health Plans]), 
* Part D ([https://www.medicare.gov/part-d/ medication interventions]). 
Most health plans are based on Medicare fee schedules, so they typically reimburse for the same or similar services.

'''Medical Interventions Activity Outcomes''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Outcomes_Insight Medical Interventions Outcomes Insight].  
* Testing - Clinical Consults, Lab, Imaging, ECG, etc.
* Qualified Option Development - diagnosis, progonosis and treatment options
* Medical Interventions
* Shared Decision Making - process helps to develop interventions based on care goals.

====Non-Medical Intervention Activities ''Determinants''====
'''Non-Medical Intervention Activities ''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Insight Non-Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

'''Non-Medical Intervention Activities Results''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Outcomes_Insight Non-Medical Interventions Outcomes Insight].
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

====Activity Changes Adherence ''Determinants''====
* Adverse Behaviors

==Health Conditions ''Determinants''==
'''Health Conditions''' Determinants that can decisively affect a patient's overall health and [http://www.patientwell-being.org/general/what-is-personal-well-being/ well-being]. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Conditions_Insight Health Conditions Insight].
===Physical Conditions ''Determinants''===
'''Physical Conditions''' Determinants can decisively affect a patient's overall health and [http://www.patientwell-being.org/general/what-is-personal-well-being/ well-being].  See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Physical_Conditions_Insight Physical Conditions Insight]. Medicare has developed a model to categorize Physical Conditions in order to risk [http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html '''risk adjust'''] health insurers that are covering patients. The [[CMS-HCC Risk Adjustments]] model adjust for patient demographics (i.e., age, disabled) and disease (i.e., diabetes, congested heart failure). 

* Allergies & Adverse Drug Reactions
* [https://en.wikipedia.org/wiki/Comorbidity Comorbidities] -  chronic disorders (or diseases) that need to be managed. Most comorbidities do not get cured.  
* Demographics - Age, Sex, Disabled, Long Term Institutional Status (LTI Designated Status) 
* [http://www.cdc.gov/vaccines/vpd-vac/vaccines-list.htm Immunizations] - Flu, Tetanus
* Physical Impairments -  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
* Physiological Metrics - Blood glucose level, Blood pressure, Cholesterol level (HDL, LDL, etc), Heart rate
* Problem and Symptom lists - Pressure Ulcers, Pain, asthma, Fever, Fractures, Headache, Rash or skin infection, Shortness of Breath, Sprains, Upper respiratory tract infection, Wounds
* [http://www.biomedcentral.com/1471-2318/14/25 '''Frailty Index''']
* [[CCS Diagnostic Categories]]

===Mental Health Conditions ''Determinants''===
'''Mental Health Conditions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Mental_Health_Conditions_Insight Mental Health Conditions Insight].
* Comorbidities -  mental health disorders (or diseases) that need to be managed. Most comorbidities do not get cured.
* Disorders - Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Autism, Bipolar Disorder, Eating Disorder, Depression, Obsessive Compulsive Disorder (OCD), Panic Disorders, Post Traumatic Stress Disorder, Schizophrenia
* History
* Impairments - Cognitive Impairments (Delirium "confused state", Dementia), Developmental

===Functional Conditions ''Determinants''===
'''Functional Conditions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Functional_Conditions_Insight Functional Conditions Insight].
* [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Activities of Daily Living (ADL’s)'''] or the ten variables in the [http://en.wikipedia.org/wiki/Barthel_scale '''Barthel scale''']
* Basic Life Activities or the [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Instrumental Activities of Daily Living (IADLs)'''] - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
* Required Devices - pacemakers, artificial limb, etc.
* Logistic Capabilities - Walk, Assisted Walking, Wheelchair, Equipment Requirements (Oxygen, heart device, etc.)
* Disabilities and Impairments as defined by the [http://www.dc37.net/about/graphics/factsheetspdf/disability_defined.pdf American Disabilities Act]
* Homebound - unable to travel to physician offices
* 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
* Mental - Not prevented from working, pursuing passion and functional activities because of mental health challenges
* [[Requires Support]] - for ADLs or IADLs
* Functional History

===Genomic Profiles ''Determinants''===
'''Genomic Profiles''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Genomic_Profiles_Insight Genomic Profiles Insight].

* [http://en.wikipedia.org/wiki/Human_genome '''Human Genome''']] - complete set of genetic information encoded as DNA sequences within the 23 chromosome pairs. It includes the genomes of [http://en.wikipedia.org/wiki/Tumor '''tumors'''], the abnormal mass of tissue from abnormal growth or division of cells. 

* [http://en.wikipedia.org/wiki/Microbiome '''Microbiome'''] - the collective genomes of the microorganisms that share our body space. The resident bacteria, viruses ([http://en.wikipedia.org/wiki/Human_virome '''virome''']) and [http://en.wikipedia.org/wiki/Eukaryote '''other microbes with genomes''']. 

* Other Genomic Profiles - [http://en.wikipedia.org/wiki/Metabolome '''Metabolome'''] - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. [http://en.wikipedia.org/wiki/Proteome '''Proteome'''] - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions.  [http://en.wikipedia.org/wiki/Transcriptome '''Transcriptome'''] - set of all molecules use to create new cells with genomes. [https://ghr.nlm.nih.gov/handbook/howgeneswork/epigenome '''epigenome''']  multitude of chemical compounds that have been added to the entirety of one’s DNA (genome) as a way to regulate the activity (expression) of all the genes within the genome. These chemical compounds of the epigenome are not part of the DNA sequence, but are on or attached to DNA (“epi-“ means above in Greek).

==Behavior ''Determinants''==
'''Behavior''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Behavior_Insight Behavior Insight]. The psychology determinants are how behavior and the mind relate to the health, social, socioeconomic, environmental and care management [[Health Determinants|determinants]].  

===Activity ''Determinants''===
'''Activity''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Activity_Insight Activity Insight].
* Physical Activity - Exercise, Activity Levels, frequency of activity (vs. long duration of sitting), Behaviors (Always walks, always drive, always buses or subways, Work (how active), Activities (Sports, Hiking, gardening)
* Sleep
* Nutrition - Diet and Nutrition (Fast Food, Take Out, Home cooked meals)
* Career/Vocation
* Passions
* Social Interactions - Engagement with others, Caregivers, Organized Communities - like [http://www.patientslikeme.com/ '''PatientsLikeMe'''], Socially Isolated, Activities (play cards, go to lunches, Social Organizations, frequent bars), Family Activities (dinners, youth sports)
* Social Activities 
* Sedentary Activities - Television (Watch Baseball, Drama series, News - Favorite programs, Other Sedentary Activities (Read, knit,etc.) 
* Spectator Activities - sports, entertainment, theater, parade, or other events
* Responsibilities Activities - Care Giver Roles to kids, parents, friends
* Travel Activities - Snowbird (summers in the North, winters in the South),Travel, Visit Family
===Adverse Behaviors ''Determinants''===
'''Adverse Behaviors''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Adverse_Behaviors_Insight Adverse Behaviors Insight].
* Alcohol, 
* Drugs, 
* Falls
* Gambling, 
* Unprotected sex, 
* Smoking

===Self-Management Behavior ''Determinants''===
'''Self-Management Behavior''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Self-Management_Behavior_Insight Self-Management Behavior Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - patient's management of interventions (Medical or Non-Medical), conditions, and symptoms based on the patient's [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Competencies_Determinants Self-Management Competencies].
* History of self-management behavior 
* Condition Management Behavior - Diabetic monitoring glucose and injecting insulin, Self-care
* Conscientiousness - behavior of doing a task well, being thorough, careful, and/or vigilant. 
* Reliable and Organized - behavior as opposed to easy-going and disorderly.
* Treatment Adherence Behavior - Medication Adherence, Nutrition, Therapy, Physician Visits, Recommended Activity levels 
* Medication Management - management and adherence of oral and injectable medicine
* Intervention Activation - Know when to ask for help, Comfortable asking for help, Know who to ask for help
* Technology Aptitude (patient or authorized care giver) - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email, Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
* Online Personal Health Record - Online Electronic Health Record, Blue Button, Access Authorization (Recovery Team access), Patient Input History (Patient answer questions or inputs data into Personal Health Record)
* Technology Usage - Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices (Blood pressure cuff, blood glucose monitoring), Remote Diagnostic Devices (ECG app, Accessing patient history via [http://www.healthit.gov/patients-families/blue-button/about-blue-button Blue Button]

==Health Competencies ''Determinants''==
'''Health Competencies''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Competencies_Insight Health Competencies Insight].

===Health Literacy ''Determinants''===
Health Literacy Determinants impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Literacy_Insight Health Literacy Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - Undertands why and how to manage their health. These competencies help improve [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Behavior_Determinants Self-Management Behavior].
* Health Risks - understand their health risks and how to manage them
* Health Conditions - understands their health conditions 
* Health Condition Management Knowledge - understands how to manage their health conditions (i.e., Diabetic glucose monitoring and injecting insulin)
* Interventions (Medical and Non-Medical)- understands why the interventions are necessary for overall health.
* Assistance Engagement - Know when to ask for help, Comfortable asking for help, Know who to ask for help
* Education - Diagnosis, Prognosis, Treatments, Understand Options and onboard with the treatment plan

===Self-Management Competencies ''Determinants''===
Self Management Competencies Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Self-Management_Competencies_Insight Self-Management Competency Insight].
* Activation Level - [http://www.insigniahealth.com/products/pam.html Patient Activation Measures] - have competencies to manage conditions, interventions (medical or non-medical) and is committed to the treatment. These competencies help improve [http://www.patientdeterminants.org/index.php?title=Health_Determinants#Self-Management_Behavior_Determinants Self-Management Behavior].
* Health Condition Management Competencies - understands how to manage their health conditions (i.e., Diabetic glucose monitoring and injecting insulin)
* Conscientiousness - a desire to do a task well being thorough, careful, or vigilant. 
* Reliable and Organized - as opposed to easy-going and disorderly.
* Intervention (Medical or Non-Medical) Competencies - Medication Adherence, Nutrition, Therapies, Physician Visits, Recommended Activity levels 
* Medication Management Competencies - management and adherence of oral and injectable medicine
* Assistance Engagement - Know when and how to ask for help, Comfortable asking for help, Know who to ask for help
* Technology Competencies (patient or authorized care giver) - Internet and Online Usage, Education Videos, Patient Portal Usage, Use of Secure Texting, Video Conferencing, email, Use of remote monitoring devices (Blood Pressure cuff, remote diagnostic devices (ecg app), Use of tablet, computer or smartphone
* Access Online Personal Health Record - Online Electronic Health Record, Blue Button, Access Authorization (Care Team access), Patient Provided Input History (Patient answer questions or inputs data into Personal Health Record)
* Technology Access - Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices

==Social ''Determinants''==
'''Social''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Social_Insight Social Insight].

===Patient (About & History) ''Determinants''===
'''Patient (About & History)''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Patient_.28About_.26_History.29_Insight Patient (About & History) Insight].
* About - Narrative/Story, Photos
* [[Marital Status]]
* '''Family''' - List of Family Members and their proximity 
* Friends - List of Friends with their proximity 
* [[Childhood Events Determinants|Childhood events]] 
* [[Childhood Upbringing Determinants|Childhood upbringing]]
* Military Service
* [[Psychosocial Circumstances Determinants|Psychosocial Circumstances]] 
* Passions/Goals - Sports Teams, Television, reading, social media, Activities - Walking, shopping, etc.
* Sexual Orientation
* [[Race & Ethnicity]]
* Country of Origin/US Born or Non-US Born

===Beliefs ''Determinants''===
'''Beliefs''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Beliefs_Insight Beliefs Insight].
* Health Literacy Beliefs
* Religion and faith
* Perspectives - politics, lifestyle, culture
* Trust and faith in Institutions - Healthcare, Education, Government
* Trust and faith in Physicians, nurses and the medical professions
* Beliefs about impacting people, caregivers, family, friends, care team
* Beliefs in whether the current care plan will work
* Beliefs about current health conditions
* Beliefs about physicial activity, nutrition and sleep
* Beliefs about adverse behavior
* Beliefs about self-management of health

===Determination ''Determinants''===
'''Determination''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Determination_Insight Determination Insight].
* Willingness to change or do something different
* Desire to make change happen
* Eagerness to learn how to improve health
* Desire to improve health
* Detrmination to stick to a plan to achieve the desired outcome
* Desire to make something happen
* Enthusiasm to make something happen
* Personal goals and dreams

===Resilience ''Determinants'' - (Psychological Fitness)===
'''Resilience''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Resilience_Insight Resilience Insight]. A patient that is psychologically fit can have a positive effect on patient outcomes. 
* ''Emotional Fitness'' -positive and negative emotions, optimism, flexible thinking, coping, character strengths 
* ''Social Fitness'' - trust, friendships, balance between privacy and loneliness
* ''Family Fitness'' - trust, friendship, intimacy, supportive dialog, manage conflict, avoid escalation
* ''Spiritual Fitness'' - religious and non-religious, what provides purpose and meaning
* ''Socioeconomic fitness'' - income, marketable job skills, savings, sources of money, 
* Stress Factors - Recent Stressful Events, Ongoing Stressful Challenge, Potential Stressful Events
* Optimism and Self-Efficacy - belief in ability to succeed in specific situations or accomplish a task which can play a major role in how one approaches goals, tasks, and challenges.
* Support system
* Sentiment - related to health, social, socioeconomic, environmental and care management [[Health Determinants|determinants]].
* 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 [http://www.umbc.edu/psyc/habits/content/ttm_measures/urica/  '''(URICA)''']
* [http://www.cdc.gov/violenceprevention/acestudy/ '''Adverse Childhood Experiences (ACE)''']
* Adversity Exposure - Violence, verbal abuse, death, poverty, financial stress, depression, anxiety

===Responsibilities ''Determinants''===
'''Responsibilities''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Responsibilities_Insight Responsibilities Insight].
* Family - Dependent Children, sick family member
* Caregiver role - for family members or friend
* Community Commitments - that helps other people
* Employment Income - that provides income, health insurance that is critical to support family
* Other Demands - pressing demands such as finish school, sell a house, resolve a legal issue.
* Personal Commitments - go to Church on Sunday, go to granddaughters soccer game
* Legal Responsibilities - criminal, civil, divorce decree, immigration, etc

===Social Well-Being ''Determinants''===
'''Social Well-Being''' Determinants can impact a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Social_Well-Being_Insight Social Well-Being Insight].
* [[Social Environment Determinants|Social Environment]] 
* Goals
* '''Purpose & Meaning''' - ''Spiritual Fitness'', part of something bigger than self, responsibilities 
* '''Competence & Success''' - ''Emotional Fitness'', Life Satisfaction, responsibilities 
* '''Passion Engagement'''  - engaging in passions, activities, social, career, religious beliefs, mindfulness, hobbies, etc.
* Perspectives
* Dignity - feeling worthy of acceptance, feeling you have something to contribute, you can accomplish things without help
* '''Connection & Love''' - feeling love or feeling meaningful connections that you believe the other person really understands you.
* ''Family'' - a sense of belonging to and having a role in a family, group of friends or community, having meaningful connections that you believe the other person really understands you. 
* '''Friendships''' - people you feel comfortable talking to, spending time with or sharing a passion with
* '''Social Status''' - how we believe we are scene within family, friends, community, work, etc.
* ''Spouse''

===Support ''Determinants''===
'''Support''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Support_Insight Support Insight]. 
* [[Social Support Group Determinants|Social support group]]
* Caregiver
* Emotional support - from family and friends, provider
* Physical support - someone who can be there physically to help
* Influential support - people who the patient trusts to help with decision making

==Socioeconomic ''Determinants''==
'''Socioeconomic''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Socioeconomic_Insight Socioeconomic Insight].
===Can't Afford Treatments ''Determinants''===
'''Can't Afford Treatments''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Can.27t_Afford_Treatments_Insight Can't Afford Treatments Insight]. 
* Delaying medical care
* Not filling prescribtion because of cost
* Not beliveing the treatment cost is worth the value

===Competencies ''Determinants''===
'''Competencies''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Competencies_Insight Competencies Insight]. 
* [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Activities of Daily Living (ADL’s)'''] or the ten variables in the [http://en.wikipedia.org/wiki/Barthel_scale '''Barthel scale''']
* Basic Life Activities or the [http://en.wikipedia.org/wiki/Activities_of_daily_living '''Instrumental Activities of Daily Living (IADLs)'''] - Clean home or setting, drive, laundry, Prepare food and/or cook, Shopping (Food, Medicines, necessities, etc., Use Public Transportation,
* [[Education and Literacy Determinants|Literacy]] - ICD Codes
* Languages - Speaking & Reading
* Technology Usage - Smart Phone, Google, Online Patient Portals

===Education ''Determinants''===
'''Education''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Education_Insight Education Insight]. 
* [[Education and Literacy Determinants|Education]] - ICD Codes
* [[Educational Attainment]] - Completed levels of formal education,
* Vocational Training
* Certifications, Licenses or degrees (diplomas)

===Financial ''Determinants''===
'''Financial''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Financial_Insight Financial Insight].
* Credit Rating
* Bankruptcy Threat
* [[Economic Circumstances Determinants|Economic circumstances]] - ICD Codes
* [[Financial Concerns]]
* Financial Health - Income, Wealth, Patient Contributions Capabilities, Financial Constraints (Debt, family commitments)  
* Financial History

===Food Insecurity ''Determinants''===
'''Food Insecurity''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Food_Insecurity_Insight Food Insecurity Insight]. 
* Missed Meals
* Low nutrition food due to cost
* Low nutrition food due to food desert

===Health Insurance ''Determinants''===
'''Health Insurance''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Insurance_Insight Health Insurance Insight].
* Employer Health Insurance, Cobra, etc. 
* Medicare, Medicaid, private plan
* Health Plan Terms - Deductibles, co-payments, provider network, etc.
* Potential eligibility for Medicaid, disability or other subsidized insurance program

===Income & Work ''Determinants''===
'''Income & Work''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Income_.26_Work_Insight Income & Work Insight].
* [[Employment Determinants|Employment challenges]] - ICD Codes
* Employment Flexibility - Sick Days/Leave Availability, Occupation
* [[Employment Level]] - ICD Codes
* [[Employment Status]] - ICD Codes
* [[Household Income]] - ICD Codes
* Income History
* Income Sources
* Income Stability - via employment, retirement or other
* Occupation
* [[Occupational Exposures Determinants|Occupational exposures]] - ICD Codes

===Legal ''Determinants''===
'''Legal''' Determinants can impact are a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Legal_Insight Legal Insight]. 
* Financial or Legal judgments
* Legal obligations
* [[Legal or Criminal Determinants|Legal or criminal]] - ICD Codes
* Legal Status - citizen status
* Pending Legal Challenges - criminal, civil, traffice violation, divorce decree, immigration, etc

==Environmental ''Determinants''==
'''Environmental''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Environmental_Insight Environmental Insight]. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy. (See: [http://www.health3-0.com/reimbursement/addressing-social-and-basic-needs/ ''Improving Clinical Outcomes By Addressing Social And Basic Needs''])

===Access & Logistics ''Determinants''===
'''Access & Logistics''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Access_.26_Logistics_Insight  Access & Logistics Insight]. 
* Necessities Access (via delivery or going to the store) - Medicines, Food (via delivery or going to the store), Other
* Public Transportation, pedestrian and bike infrastructure to promote physical activity
* Unsafe pedestrian crossings increase risk of injury
* Transportation - Physician Offices, shopping, activities, 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)

===Communication ''Determinants''===
'''Communication''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Communication_Insight Communication Insight].

The physical form of available communications.
* Phone
* Internet
* Text Messaging
* Mail
* Face-to-face
* Mobile Apps
* Through caregiver

===Community ''Determinants''===
'''Community''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Community_Insight Community Insight]. 
* [[Physical Environment Determinants|Physical environment]]
* Neighborhood - safe, places to walk, amenities within walking distance, 
* Supportive Neighbors - friendly, quiet at night (able to get restful sleep), someone to check in nearby 
* Amenities - proximity to groceries, pharmacy, parks, etc., density of liquor stores can increase use
* Proximity to child care, clinics and jobs 
* Transportation Access
* Social events
* Food deserts - lack of fresh foods
* Clinical Care Services
* Air Quality - pollution may degrade indoor air quality and increase risk of asthma, heart disease and other illnesses
* Crime 
* Noise - from roadways, industry and airports can degrade quality of sleep

===Home ''Determinants''===
'''Home''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Home_Insight Home Insight]. 
* [[Physical Environment Determinants|Physical environment]] - exposure to noise, air pollution, water pollution, soil pollution, radiation, other pollution, inadequate drinking-water supply, tobacco smoke (passive smoking)
* [[Housing Circumstances Determinants|Housing circumstances]] - Homelessness, Inadequate housing (Lack of heating, Restriction of space, Technical defects), Discord with neighbors, lodgers and landlord, Problems related to living in residential institution (Boarding-school resident), problems related to housing and economic circumstances (Foreclosure on loan, Isolated dwelling, Problems with creditors) 
* Housing Costs - affect ability to afford food and other essential basic needs
* Housing Structure - Old Carpet and mold can trigger asthma, Structural problems increase the risk of falls and burns, stairway design can promote exercise, safety amenities (banisters, smoke alarms, etc.), Accessibility (Wheel Chair accessible)
* Home Furnishing - Throw rugs (falls, recent hip replacements) 
* Home - Environmental (Heat, Air conditioner, water, hot water)
* Exposure to firearms
* Exposure to opioids  
* Household members - disruptive/supportive family member, Onsite Care Giver Support or from family members
* Living Arrangement - living alone, congregate living, etc.
* Private Facility - Apartment, House, Room, etc.
* Institution 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, Mold), 
* Temporary Housing - Homelessness, Homeless Shelters, friend or family members home, Halfway House (after recent prison term), Victim Shelters (domestic and sexual violence, disaster relief)

===Security ''Determinants''===
'''Security''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Security_Insight Security Insight]. 

===Technology & Apps ''Determinants''===
'''Technology & Apps''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Technology_.26_Apps_Insight Technology & Apps Insight]. 
* Apps - mobile, computer applications 
* Durable Medical Equipment - Oxygen equipment, nebulizers, Continuous positive airway pressure (CPAP) devices, single and bi-level, manual and power wheelchairs, scooters, and walkers
* Home Technology - wifi, broadband internet, cable TV, phone 
* Mobile - cell phone, cell phone service
* Passive Sensors (wifi enabled weight scale, blue tooth enabled blood pressure cuff)

==Content ''Determinants''==
'''Content''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Content_Insight Content Insight].

===Medical Records Determinants=== 
'''Medical Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Records_Insight Medical Records Insight].
* Comprehensive Medical Record - Ensure one location has combined medical records from multiple providers, such as a Primary Care Physician office. 
* Accurate - Ensure the Medical Record ion accurate
* Preventitive Care - Ensure recommended Home Technology - wifi, broadband internet, cable TV, phone 
* No Care Gaps - Ensure their are no open care gaps (i.e., diabetic, yet no hA1C test in past 6 months
* Diagnosis Codes (ICD-10 Codes)
* Physical and Mental Health Biomarkers - Blood Pressure, HbA1C blood test, cholesterol, Depression, Anxiety, etc.
* [[Symptoms]] 
* [http://www.patientdeterminants.org/index.php?title=Determinants#Functional_Conditions_Determinants Functional Conditions]
* Quality of Life Limitations - [http://www.patientdeterminants.org/index.php?title=Determinants#Activity_Determinants Activity], [http://www.patientdeterminants.org/index.php?title=Determinants#Socioeconomic_Determinants Socioeconomic] and [http://www.patientdeterminants.org/index.php?title=Determinants#Social_Determinants Social]
* Advanced Directives
* Preferences - Authorizations, Living Will, etc.
* [[Medical Interventions]] and [[Non-Medical Interventions]]

===Health Determinants Records=== 
'''Health Determinants Records''' can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Determinants_Records_Insight Health Determinants Records Insight].
* Methods of capturing Health Determinants
* Record of Health Determinants
* Patient Generated Data

===Health Interventions Records Determinants===
'''Health Interventions Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Interventions_Records_Insight Health Interventions Records Insight].
* History of Interventions (Medical and Non-Medical)
* Current Health Interventions

===Health Outcomes Records Determinants===
'''Health Outcomes Records''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Outcomes_Records_Insight Health Outcomes Records Insight].
* Health Outcomes tied to Health Determinants and Health Interventions
* Current Health Outcome Plans
* History of Health Outcomes
* Patient Reported Outcomes

==Care Management ''Determinants''==
'''Care Management''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Management_Insight Care Management Insight].

===Health Mission & Care Goals ''Determinants''===
'''Health Mission & Care Goals''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Mission_.26_Care_Goals_Insight Health Mission & Care Goals Insight].
* Patient's Health Mission
* Patient's Care Goals

===Health Strategies & Care Planning ''Determinants''===
'''Health Strategies & Care Planning''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Strategy_.26_Care_Planning_Insight Health Strategy & Care Planning Insight]. 
* Medications - [https://en.wikipedia.org/wiki/Polypharmacy Polypharmacy] is patients on 4 or more medicines.
* Procedures and Surgery
* Therapies (Occupational Therapy, Speech, Physical Therapy)
* Activities - Nutrition, Education, quit smoking, etc,
* Performance Measures
** Recovery Plan - Effectiveness of recovery team, Effectiveness of Protocols for response and escalations, Appropriateness of Recovery Goals 
** Medication efficacy (effectiveness, interactions, adverse events), 
** Effectiveness of Treatments and Activities,

===Health Disciplines & Resources ''Determinants''===
'''Health Disciplines & Resources''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Disciplines_.26_Resources_Insight Health Disciplines & Resources Insight]. 
* Clinical Providers - These are licensed professionals. Primary Care Physicians, Physician Assistants, Nurse Practitioners, Physician Specialists, 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 friend), Recovery Navigator (patient navigator), Recovery Coaches (included MSW Social Workers and Health Coaches), Education (Non-Clinical), Technical Support and technicians
* Community (Basic Needs) Resources - 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)

===Care Management - Communications ''Determinants''===
'''Care Management Communications''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Management_-_Communications_Insight Care Management - Communications Insight].  
* Patient communication - Who? (with care team), How? (in-person, phone, email, text, apps) Frequency? (i.e., dailly, as-needed)
* Patient Inquiries - who? how? response time?
* Patient Status - Symptoms, Problem Lists, Concerns, Functional Status, risk factors, Quality of Life Opportunity
* Recovery Plan Activities - ensure activities are scheduled, treatments happen, prescriptions filled, Recovery Team performs function, Status of Surgeries, Procedures, Tests, Therapies, etc.  
* Patient Adherence - Monitoring of Medication Adherence, activity levels, other patient behaviors, etc.
* Patient Activation - Understand condition, capable of treating self, etc. 
* Recovery Factors Monitored - Clinical Condition - Physiological Metrics (i.e., Blood Pressure), Pain, Wounds, etc., functional conditions, etc.  
* Monitoring Method - Daily Calls, Patient checks box or inputs data, Passive sensors (wifi enabled pill boxes or caps)

===Care Management - Operational ''Determinants''===
'''Care Management - Operational''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Management_-_Operational_Insight Care Management - Operational Insight]. 
* Communication methods within care team - phone, text, portal, etc.
* Arranging diagnosis, second opinions, procedures, etc.
* Patient Navigation
* Triggers - Triggers Requiring Notifications - Patient Concern, Monitoring Alert (i.e., Medication adherence, blood pressure reading), 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 are they notified (phone calls, text message, alerts)? When are they notified (time frame)?
* Associated Action - Who takes the action? What is the action? How do they take the action (phone calls, text message, alerts)? When do they take action (time frame)? 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 take action?

==Health Interventions ''Determinants''==
'''Health Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Health_Interventions_Insight Health Interventions Insight].
===Medical Interventions ''Determinants''===
'''Medical Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Insight Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* Part A ([https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-costs.html hospital/facility interventions]), 
* Part B ([https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html physician interventions]), 
* Part C ([https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html Medicare Advantage Health Plans]), 
* Part D ([https://www.medicare.gov/part-d/ medication interventions]). 
Most health plans are based on Medicare fee schedules, so they typically reimburse for the same or similar services.

===Medical Interventions Outcomes ''Determinants''===
'''Medical Interventions Outcomes''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Medical_Interventions_Outcomes_Insight Medical Interventions Outcomes Insight].  
* Testing - Clinical Consults, Lab, Imaging, ECG, etc.
* Qualified Option Development - diagnosis, progonosis and treatment options
* Medical Interventions
* Shared Decision Making - process helps to develop interventions based on care goals.

===Non-Medical Interventions ''Determinants''===
'''Non-Medical Interventions''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Insight Non-Medical Interventions Insight].
Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare. 
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

===Non-Medical Interventions Outcomes ''Determinants''===
'''Non-Medical Interventions Outcomes''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Non-Medical_Interventions_Outcomes_Insight Non-Medical Interventions Outcomes Insight].
* [[Care Management Programs]] - team-based, patient focused programs designed to meet specific needs of patients based on the program's criteria. 
* [[Health Services]] - a specific focused health services or capabilities designed to meet specific health needs of patients based on the services's criteria. 
* [[Support Services]] - a specific focused support services or capabilities designed to meet specific needs of patients based on the services's criteria. 
* [[Patient/Caregiver Interventions]] - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.
* [[Health Insurance Payment Models]] - these are health insurance payment models design to improve patients outcomes, health and reduce cost
* [[Organization Interventions]] - employers, communities and governments interventions

==People ''Determinants''==
'''People''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#People_Insight People Insight].These are people that may support and/or influence the overall health.  
===Family Members & Friends ''Determinants''===
'''Family Members & Friends''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Family_Members_.26_Friends_Insight Family Members & Friends Insight].
* Spouse or Signicant Other
* Parents 
* Siblings
* Children
* In-Laws
* Step-Family 
* Friends - List of Friends with their proximity

===Care Team & Resources ''Determinants''===
'''Care Team & Resources''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Care_Team_.26_Resources_Insight Care Team & Resources Insight].

Providers of resources. Medical or non-medical that could influence health outcomes
* Clinical Providers - These are licensed professionals. 
** Primary Care Physicians 
** Physician Specialists 
** Advanced Practice Professional (APPs)  - Physician Assistants, Nurse Practitioners, 
** Pharmacists, 
** Therapists - Physical Therapists (PT) / Occupational Therapists (OT) / Speech Therapists (ST)
** Behavior Health (Psychologist, Psychiatrist), 
** Clinical Social Worker - Licensed Social Workers (LSW) or Medical Social Workers (MSW)
** Nurses (Care Manager) Registered Nurses (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
** Dietitians 
** Clinical Educators Providers
* Credentialed Support (Social and Behavioral) Providers - These are professionals that required some credentialing. 
** Home Health - Certified Nursing Assistants (CNA) / Home Health Aides (HHA)
** Medical Assistants 
** Behavioral Health 
** Patient Navigator - Recovery Navigator 
** Health Coaches - Recovery Coaches 
** Social Workers 
** Legal Counselors
** Home Health 
* Non-Credentialed Providers
** Care givers (family or friend),
** Financial Counselors
** Community Health Workers
** Technical Support - Technical Support and technicians
* Community (Basic Needs) Resources  
** Meals Delivery (Meals on Wheels), 
** Transportation Assistance and Services 
** Programs (Smoking Cessation, 
** Weight Loss, Alcoholics Anonymous), 
** Home Maintenance Services - handy man, plumber, etc. 
** Community Health Centers - free flu shots, etc.
** Convenient Care (Minute Clinics, 24 hour services)

===Other Contributors ''Determinants''===
'''Other Contributors''' Determinants can decisively affect a patient's overall health and well-being. See [http://www.patientdeterminants.org/index.php?title=Health_Insight#Other_Contributors_Insight Other Contributors Insight]. 
* Other Key Contributers 
* Influencers - Work Supervisor, Teacher
* Volunteers
* Other Providers

==Communities ''Determinants''==
'''Communities''' Determinants can decisively affect a patient's overall health and well-being. These are communities that may support and/or influence the overall health.  
===Family===
===Industries===
* Retail Pharmacies
* Pharmaceutical 
* Medical Devices

===Institutions===
* Government
* Healthcare 
* Education
* Research
* Health Insurers

===Location===
* Neighborhood
* Town
===Organizations ===
* Employers
* Governments 
* Hospital 
* Medical Practices