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 (Health Goals) Insight.

Personal Goals (Missions) Determinants

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

Health Goals (Care Goals) Determinants

Health Goals (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

Strategy (Health Plan) Determinants can impact a patient's health outcomes and health status. See Strategy (Health Plan) 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

Intervention Adherence Determinants

Intervention Changes Determinants

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 (Health Goals) Measures - measure progress toward achieving the mission
- Strategy Objectives (Care Plan) Measures - measure the progress of the strategy objectives toward achieveing the mission
- Strategy Solutions (Interventions) 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
- Adherence Measures - adherence to interventions
- Change Measures - timing, reason codes, for changes in interventions, people, realities, activities
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

Strategy - Impacting People Determinants can decisively affect a patient's overall health and well-being. See Health Disciplines & Resources Insight.

List - Impacting People

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)
Changes to Impacting People List

Roles - Impacting People

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

Behavior - Impacting People Behavior

Adherence to Strategy
Frequency and types of communications
Influence
Activities
Tasks
Support Provided

Potential Barriers - Impacting People

List of potential barriers due to impacting people
Potential Impact of Potential Barriers
How potential barriers can be addressed
Strategy to address potential barriers
Effectiveness of potential barriers being addressed
Changes to how potential barriers are being addressed

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 - Impacting Realities

Health Conditions
Competencies
Social
Socioeconomic
Environmental
Digital Content & Technology
Changes to Impacting Realities List

Potential Barriers - Impacting Realities

List of potential barriers due to impacting realities
Potential Impact of Potential Barriers
How potential barriers can be addressed
Strategy to address potential barriers
Effectiveness of potential barriers being addressed
Changes to how potential barriers are being addressed

Strategy - Impacting Activities Determinants

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

List - Impacting Activities

Physical Activities
Social & Passion Activities
Nutrition
Functional Activities
Sleep
Stress, Emotions & Meditation
Adverse Behaviors
Self-Management Behavior
Care Management Communications
Care Management Operational
Health Strategy Activities

Behavior - Impacting Activities

Adherence to Strategy
Changes to Behavior
Potential Assets from Behavior

Potential Barriers - Impacting Activities

List of potential barriers due to impacting activities
Potential Impact of Potential Barriers
How potential barriers can be addressed
Strategy to address potential barriers
Effectiveness of potential barriers being addressed
Changes to how potential barriers are being addressed

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 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.

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).

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.

High Cost High Need Patients Determinants

High Cost High Need Patients Determinants can decisively affect a patient's overall health and well-being. See Genomic Profiles Insight.

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 - demonstrates 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 - demonstrates abilities 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.

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 & Technology 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.

Communities

Healthcare Organizations

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

Government Organizations

Town
County
State
Federal

Employer

Community and Social Services Organizations

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

Support Resources Organizations

Other Contributors Determinants

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

Healthy Lifestyle Determinants

Overall Healthy Lifestyle Determinants can decisively affect a patient's overall health and well-being. See Activity Insight.

Physically Active
Nutrition
Healthy Weight
Avoid Adverse Behaviors
Self Care Management of Health - Sleep, Meditation, preventitive care, medication adherence, etc.
Social & Passion Activities

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
Use of technology such as internet, computers, smart phones, medical deveices, etc.

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 Planning Activities Determinants

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