Health Determinants

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

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 are health condition determinants of 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 are health condition determinants of 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 are health condition determinants of 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 are health condition determinants of 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.
  • 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 are behavior determinants of 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)
  • Adverse Behaviors - use of alcohol, drugs, gambling, unprotected sex, smoking
  • 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

Self-Management Behavior Determinants

Self-Management Behavior Determinants impact a patient's overall health and well-being. See Patient Activation 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
  • Health Literacy - understand health and how to impact it
  • Condition Management Aptitude - Diabetic monitoring glucose and injecting insulin, Self-care
  • Conscientiousness - a desire to do a task well being thorough, careful, or vigilant. Efficient and organized as opposed to easy-going and disorderly.
  • Education - Diagnosis, Prognosis, Treatments, Understand Options and onboard with the treatment plan
  • Treatment Adherence - 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
  • PC Interventions - activities or actions by patients and caregivers that will likely improve health, health outcomes and reduce overall cost.

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 Activity 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 impact a patient's overall health and well-being. See Activity 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 - See [[

Broadband Internet, Wifi Router, Telecom Network (AT&T, Verizon), Computer, Smartphone or Tablet, Remote Monitoring Devices


Resilience Determinants - (Psychological Fitness)

Resilience Determinants are behavior determinants of 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

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 are social determinants of 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
  • Health Literacy
  • Legal or criminal
  • Languages Speaking
  • Military Service
  • Psychosocial Circumstances
  • Passions/Goals - Sports Teams, Television, reading, social media, Activities - Walking, shopping, etc.
  • Perspectives - politics, lifestyle, culture
  • Sexual Orientation
  • Race & Ethnicity
  • Country of Origin/US Born or Non-US Born
  • Religious Beliefs - Religion and religious beliefs

Responsibilities Determinants

Responsibilities Determinants are social determinants of 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 - criminal, civil, traffic, divorce decree, immigration, etc

Social Well-Being Determinants

Social Well-Being Determinants are social determinants of 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 are social determinants of 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. ICD Codes

Income & Work Determinants

Income & Work Determinants are socioeconomic determinants of a patient's overall health and well-being. See Income & Work Insight.

Financial Determinants

Financial Determinants are socioeconomic determinants of a patient's overall health and well-being. See Financial Insight.

  • Credit Rating
  • Bankruptcy Threat
  • Economic circumstances
  • Financial Concerns
  • Financial Health - Income, Wealth, Patient Contributions Capabilities, Financial Constraints (Debt, family commitments)
  • Financial History
  • Legal - judgments, financial legal obligations

Health Insurance Determinants

Health Insurance Determinants are socioeconomic determinants of 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

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 are environmental determinants of 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)

Community Determinants

Community Determinants are environmental determinants of 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 are environmental determinants of 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)

Technology & Apps Determinants

Technology & Apps Determinants are environmental determinants of 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 Record Determinants

  • 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

Determinats of Health Records

  • Record of Health Determionants
  • Patient Reports Outcomes
  • Patient Generated Data Accurate

Health Intervention Records

  • History of Interventions (Medical and Non-Medical)
  • Current Health Interventions

Health Outcomes

  • Current Health Outcome Plans
  • Hitory of Health Outcomes

Health Management Determinants

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

Care Goals & Plans Determinants

Care Goals & Plans Determinants are care management determinants of a patient's overall health and well-being. See Care Goals & Plans Insight.

Care Coordination & Protocols Determinants

Care Coordination & Protocols Determinants are care management determinants of a patient's overall health and well-being. See Care Coordination & Protocols Insight.

  • Communication within care team
  • 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?

Care Team & Services Determinants

Care Team & Services Determinants are care management determinants of a patient's overall health and well-being. See Care Team & Services 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) Providers - 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)
  • E Interventions - interventions which receive no reimbursement from traditional health insurance and will likely improve health, health outcomes and reduce overall cost.

Healthcare Interventions Determinants

Healthcare Interventions Determinants are care management determinants of a patient's overall health and well-being. See Healthcare Interventions 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,

Medical Decisions Determinants

Medical Decisions Determinants are care management determinants of a patient's overall health and well-being. See Medical Decisions 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.

Patient Dialog & Monitoring Determinants

Patient Dialog & Monitoring Determinants are care management determinants of a patient's overall health and well-being. See Patient Dialog & Monitoring 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 - 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)
  • Recovery Plan Effectiveness - Medication efficacy (effectiveness, interactions, adverse events), Effectiveness or Treatments and Activities, Effectiveness of recovery team, Effectiveness of Protocols, Appropriateness of Recovery Goals
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