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 (Health Goals) Determinants

Health Mission Determinants can impact a patient's health outcomes and health status. See Health Mission Insight.

Personal Missions Determinants

Personal Missions Determinants can decisively affect a patient's overall health and well-being. See Health Mission & Care Goals Insight. Patient specific care goals realted to improving or maintaining the patient's health status.

• Patient's Life Mission - non health related, responsibilities, passions, etc.
• Patient's Health Mission - that includes preventitive & wellness goals, managing acute and chronic conditions, end-of-life

Care Goals Determinants

Care Goals Determinants can decisively affect a patient's overall health and well-being. See Health Mission & Care Goals Insight. Patient specific care goals realted to improving or maintaining the patient's health status.

• Symptoms Goals (Patient) - improvement of patient's assessment of their physical and mental symptoms. They include pain or discomfort, visual symptoms, cold or flu-like, physical abnormalities, mental health and other.
• Conditions Goals (Medical) - improvement or stabilizing disease and conditions (i.e., diabetes, hypertension) as well as biomarkers (i.e., blood pressure, weight, blood glucose) as documented by a medical professional in the patients Electronic Medical Record.
• Function Goals (Patient) - improvement of the patient's assessment of their function (i.e., walking, going to work, doing what they love).
• Clinical Risk Goals (Medical) - improvement of medical risks (i.e., for disease, disease progression, acute event, mortality)
• Behavioral Risk Goals (Patient) - improvement of the patients assessment of their behavior or ability to be compliant with the care plan based on health determinants (i.e., fiancial, transportation, housing).
• Well-Being Goals (Patient) - improvement in the patient's assessment of Support, Health, Basic Needs, PHQ, Purpose, Love & Connection, Competence
• Timing Goals - 2 days, 2 weeks, 2 months, 2 years
• Medical Interventions & Events Goals - Acute events, surgeries, ER visit, hospital, medication or medical treatment etc.

Strategy (Health Plan) Determinants

Health Strategy Determinants can impact a patient's health outcomes and health status. See Health Strategy Insight.

Strategy Objectives (Care Plan) Determinants

Strategy Objectives (Care Plan) Determinants can decisively affect a patient's overall health and well-being. See Care Plan Insight.

• Overall Strategy objectives of how each of the care goals will be achieved
• Specific details of how each of the care goals will be achieve
• Potential Barriers (Impacting Activities, People, & Realities) - potential barriers (health determinants) that could impact achieving the Care Goals and how each will be addressed
• Key People & Roles (Impacting People)
• Key Activities & Interventions (Impacting Activities)
• Measures

Strategy Solutions (Interventions) 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 can impact the strategy:

• 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 can impact the Care Plan

Strategy Measures Determinants

Strategy Measures Determinants can decisively affect a patient's overall health and well-being. See Care Plan Insight.

• Measures - These are measures that will demonstrate progress toward achieving the health mission. This is the list of measures (i.e., pain levels, function levels, blood sugar levels) that will be used to measure progress of the startegy objectives toward achieving the health mission.
• Measures types:
  • Mission Measures - measure progress toward achieving the mission
  • Strategy Objectives Measures - measure the progress of the strategy objectives toward achieveing the mission
  • Strategy Solutions Measures - measure the effectiveness of individual interventions in respect to achieving the missio and objective strategy
  • Impacting Elements Measures - measure the impact of impacting people, realities and activities not included above
• Measurement Timeframes - These are the times when progress will be measures
• Measurement Baseline - This is the initial measures that will be used to measure the health outcome of the strategy objectives.

Strategy - Impacting People Determinants

List of Impacting People 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)

Roles of Impacting People

• Role within Strategy (Care Plan)
• Frequency and types of communications
• Influence
• Tasks
• Types of Support

Potential Barriers from Impacting People
Potential Impact of the Potential Barriers from Impacting People
Changes of Impacting People
Strategy Adherence of Impacting People

Strategy - Impacting Realities Determinants

Strategy - Impacting Realities Determinants (Health Determinats) can decisively affect a patient's overall health and well-being. See Care Plan Insight.
List of Impacting Realities
List of Potential Barriers from Impacting Realities
Potential Impact of the Potential Barriers from Impacting Realities
Changes to Impacting Realities

Strategy - Impacting Activities Determinants

Strategy - Impacting Activities Determinants can decisively affect a patient's overall health and well-being. See Strategy - Impacting Activities Insight. Strategy - Impacting Realities Determinants (Health Determinats) can decisively affect a patient's overall health and well-being. See Care Plan Insight.
List of Impacting Activities
List of Potential Barriers from Impacting Activities
Potential Impact of the Potential Barriers from Impacting Activities
Changes to Impacting Activities

Impacting Realities Determinants

Impacting Realities Determinants can impact a patient's health outcomes and health status. See Impacting Realities Insight.

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

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

Functional Competencies Determinants

Functional 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
• 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

Relationships Determinants

Relationships Determinants can impact a patient's overall health and well-being. See Relationships Insight. A patient with good or functional relationships with the Impacting People can have a positive effect on patient outcomes. The relationship type, type and frequency of communication as well as what is recieved from the relationship.

• Physicians
• Care Team members
• Caregivers
• Family & Friends
• Support Team
• Organizations
• Other Contributors

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)
• 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 Security Insight.

Digital Content & Techology Determinants

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

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)

Impacting People Determinants

Impacting People Determinants can impact a patient's health outcomes and health status. See Impacting People Insight.

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

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 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 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

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

Impacting Activities Determinants can impact a patient's health outcomes and health status. See Impacting Activities Insight.

Physical Activities Determinants

Physical Activities Determinants can decisively affect a patient's overall health and well-being. See 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 Activity Insight.

• Social Interactions - Engagement with others, Caregivers, Organized Communities - like 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 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 Activity Insight.

• Education Activities
• Income & Work activities
• Home maintenance
• 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,
• 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 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 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 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 Strategy Activities Determinants

Medical Intervention Activities 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 Activity 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 Intervention Activities Determinants

Non-Medical Intervention Activities 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 Intervention Activities Results 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

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