Health Determinants

Health Determinants can decisively affect a patient's overall health and well-being. Health Determinants include barriers, symptoms and functional status. The Institute of Medicine (IOM) recommends capturing social and behavioral determinants in Electronic Medical Records. 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 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 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 Health Strategy & Care Planning Insight.

Care Plan Determinants

Care Goals Determinants can decisively affect a patient's overall health and well-being. See Health Mission & Care Goals Insight.

• Medications - 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 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 Activities Determinants

Medical Interventions Determinants

Medical Interventions Determinants can decisively affect a patient's overall health and well-being. See Medical Interventions Insight. Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare.

• Part A (hospital/facility interventions),
• Part B (physician interventions),
• Part C (Medicare Advantage Health Plans),
• 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 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 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

Non-Medical Interventions Outcomes Determinants can decisively affect a patient's overall health and well-being. See 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

Impacting Realities

Health Conditions Determinants

Health Conditions Determinants that can decisively affect a patient's overall health and well-being. See Health Conditions Insight.

Physical Conditions Determinants

Physical Conditions Determinants can decisively affect a patient's overall health and well-being. See Physical Conditions Insight. Medicare has developed a model to categorize Physical Conditions in order to risk 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
• 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)
• 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
• 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 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 Functional Conditions Insight.

• Activities of Daily Living (ADL’s) or the ten variables in the Barthel scale
• Basic Life Activities or the 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 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 Genomic Profiles Insight.

• Human Genome] - complete set of genetic information encoded as DNA sequences within the 23 chromosome pairs. It includes the genomes of tumors, the abnormal mass of tissue from abnormal growth or division of cells.

• Microbiome - the collective genomes of the microorganisms that share our body space. The resident bacteria, viruses (virome) and other microbes with genomes.

• Other Genomic Profiles - Metabolome - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. Proteome - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions. Transcriptome - set of all molecules use to create new cells with genomes. 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

Health Competencies Determinants can decisively affect a patient's overall health and well-being. See Health Competencies Insight.

Health Literacy Determinants

Health Literacy Determinants impact a patient's overall health and well-being. See Health Literacy Insight.

• Activation Level - Patient Activation Measures - Undertands why and how to manage their health. These competencies help improve 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 Self-Management Competency Insight.

• Activation Level - Patient Activation Measures - have competencies to manage conditions, interventions (medical or non-medical) and is committed to the treatment. These competencies help improve 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

Competencies Determinants

Competencies Determinants can impact are a patient's overall health and well-being. See Competencies Insight.

• Activities of Daily Living (ADL’s) or the ten variables in the Barthel scale
• Basic Life Activities or the 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,
• 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 Education Insight.

• 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 Social Insight.

Patient (About & History) Determinants

Patient (About & History) Determinants can impact a patient's overall health and well-being. See 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
• Childhood upbringing
• Military Service
• 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 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 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 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 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 (URICA)
• 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 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 Social Well-Being Insight.

• 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 Support Insight.

• 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 Socioeconomic Insight.

Can't Afford Treatments Determinants

Can't Afford Treatments Determinants can impact are a patient's overall health and well-being. See 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 Financial Insight.

• Credit Rating
• Bankruptcy Threat
• 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 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 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 Income & Work Insight.

• 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 - ICD Codes

Legal Determinants

Legal Determinants can impact are a patient's overall health and well-being. See Legal Insight.

• Financial or Legal judgments
• Legal obligations
• 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 Environmental Insight. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy. (See: Improving Clinical Outcomes By Addressing Social And Basic Needs)

Access & Logistics Determinants

Access & Logistics Determinants can decisively affect a patient's overall health and well-being. See 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 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 Community Insight.

• 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 Home Insight.

• Physical environment - exposure to noise, air pollution, water pollution, soil pollution, radiation, other pollution, inadequate drinking-water supply, tobacco smoke (passive smoking)
• 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 Security Insight.

Technology & Apps Determinants

Technology & Apps Determinants can decisively affect a patient's overall health and well-being. See 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 Content Insight.

Medical Records Determinants

Medical Records Determinants can decisively affect a patient's overall health and well-being. See 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
• Functional Conditions
• Quality of Life Limitations - Activity, Socioeconomic and 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 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 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 Health Outcomes Records Insight.

• Health Outcomes tied to Health Determinants and Health Interventions
• Current Health Outcome Plans
• History of Health Outcomes
• Patient Reported Outcomes

Impacting People Determinants

Impacting People Determinants can decisively affect a patient's overall health and well-being. See 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 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

Family Members & Friends Determinants

Family Members & Friends Determinants can decisively affect a patient's overall health and well-being. See Family Members & Friends Insight.

• 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 Care Team & Resources Insight.

• Educators
• 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

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.

Other Contributors Determinants

Other Contributors Determinants can decisively affect a patient's overall health and well-being. See Other Contributors Insight.

• Manager or Superviosr at Work
• Other Key Contributers
• Influencers - Teacher
• Volunteers
• Other Resources of Providers

Impacting Activities Determinants

Behavior Determinants can decisively affect a patient's overall health and well-being. See Behavior Insight. The psychology determinants are how behavior and the mind relate to the health, social, socioeconomic, environmental and care management determinants.

Behavior Determinants

Behavior Determinants can decisively affect a patient's overall health and well-being. See 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 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 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 Self-Management Behavior Insight.

• Activation Level - Patient Activation Measures - patient's management of interventions (Medical or Non-Medical), conditions, and symptoms based on the patient's 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 Blue Button

Care Management - Communications Determinants

Care Management Communications Determinants can decisively affect a patient's overall health and well-being. See 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 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 Conditions Determinants

Health Conditions Determinants that can decisively affect a patient's overall health and well-being. See Health Conditions Insight.

Physical Conditions Determinants

Physical Conditions Determinants can decisively affect a patient's overall health and well-being. See Physical Conditions Insight. Medicare has developed a model to categorize Physical Conditions in order to risk 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
• 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)
• 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
• 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 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 Functional Conditions Insight.

• Activities of Daily Living (ADL’s) or the ten variables in the Barthel scale
• Basic Life Activities or the 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 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 Genomic Profiles Insight.

• Human Genome] - complete set of genetic information encoded as DNA sequences within the 23 chromosome pairs. It includes the genomes of tumors, the abnormal mass of tissue from abnormal growth or division of cells.

• Microbiome - the collective genomes of the microorganisms that share our body space. The resident bacteria, viruses (virome) and other microbes with genomes.

• Other Genomic Profiles - Metabolome - are small molecules with metabolism functions of fuel, structure, signaling, stimulatory and inhibitory effects on enzymes and other catalytic activities. Proteome - set of proteins expressed by a genome, cell, tissue or organism at a given time, under defined conditions. Transcriptome - set of all molecules use to create new cells with genomes. 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 Behavior Insight. The psychology determinants are how behavior and the mind relate to the health, social, socioeconomic, environmental and care management determinants.

Activity Determinants

Activity Determinants can decisively affect a patient's overall health and well-being. See 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 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 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 Self-Management Behavior Insight.

• Activation Level - Patient Activation Measures - patient's management of interventions (Medical or Non-Medical), conditions, and symptoms based on the patient's 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 Blue Button

Health Competencies Determinants

Health Competencies Determinants can decisively affect a patient's overall health and well-being. See Health Competencies Insight.

Health Literacy Determinants

Health Literacy Determinants impact a patient's overall health and well-being. See Health Literacy Insight.

• Activation Level - Patient Activation Measures - Undertands why and how to manage their health. These competencies help improve 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 Self-Management Competency Insight.

• Activation Level - Patient Activation Measures - have competencies to manage conditions, interventions (medical or non-medical) and is committed to the treatment. These competencies help improve 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 Social Insight.

Patient (About & History) Determinants

Patient (About & History) Determinants can impact a patient's overall health and well-being. See 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
• Childhood upbringing
• Military Service
• 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 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 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 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 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 (URICA)
• 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 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 Social Well-Being Insight.

• 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 Support Insight.

• 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 Socioeconomic Insight.

Can't Afford Treatments Determinants

Can't Afford Treatments Determinants can impact are a patient's overall health and well-being. See 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 Competencies Insight.

• Activities of Daily Living (ADL’s) or the ten variables in the Barthel scale
• Basic Life Activities or the 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,
• 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 Education Insight.

• 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 Financial Insight.

• Credit Rating
• Bankruptcy Threat
• 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 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 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 Income & Work Insight.

• 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 - ICD Codes

Legal Determinants

Legal Determinants can impact are a patient's overall health and well-being. See Legal Insight.

• Financial or Legal judgments
• Legal obligations
• 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 Environmental Insight. The top unmet basic needs that effect clinical outcomes are: housing, food, finances, transportation and literacy. (See: Improving Clinical Outcomes By Addressing Social And Basic Needs)

Access & Logistics Determinants

Access & Logistics Determinants can decisively affect a patient's overall health and well-being. See 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 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 Community Insight.

• 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 Home Insight.

• Physical environment - exposure to noise, air pollution, water pollution, soil pollution, radiation, other pollution, inadequate drinking-water supply, tobacco smoke (passive smoking)
• 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 Security Insight.

Technology & Apps Determinants

Technology & Apps Determinants can decisively affect a patient's overall health and well-being. See 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 Content Insight.

Medical Records Determinants

Medical Records Determinants can decisively affect a patient's overall health and well-being. See 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
• Functional Conditions
• Quality of Life Limitations - Activity, Socioeconomic and 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 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 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 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 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 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 Health Strategy & Care Planning Insight.

• Medications - 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 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 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 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 Health Interventions Insight.

Medical Interventions Determinants

Medical Interventions Determinants can decisively affect a patient's overall health and well-being. See Medical Interventions Insight. Healthcare treatments and services that are typically reimbursed by healthcare insurances like Medicare.

• Part A (hospital/facility interventions),
• Part B (physician interventions),
• Part C (Medicare Advantage Health Plans),
• 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 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 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 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 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 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 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 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.

Industries

• Retail Pharmacies
• Pharmaceutical
• Medical Devices

Institutions

• Government
• Healthcare
• Education
• Research
• Health Insurers

Location

• Neighborhood
• Town

Organizations

• Employers
• Governments
• Hospital
• Medical Practices