U.S. patent application number 13/439565 was filed with the patent office on 2012-07-26 for system and method of prioritizing and administering healthcare to patients having multiple integral diagnoses.
Invention is credited to Debra Thesman.
Application Number | 20120191472 13/439565 |
Document ID | / |
Family ID | 38369828 |
Filed Date | 2012-07-26 |
United States Patent
Application |
20120191472 |
Kind Code |
A1 |
Thesman; Debra |
July 26, 2012 |
SYSTEM AND METHOD OF PRIORITIZING AND ADMINISTERING HEALTHCARE TO
PATIENTS HAVING MULTIPLE INTEGRAL DIAGNOSES
Abstract
A method of administering healthcare to patients with multiple
integral diagnoses such that the clinical outcomes and
health-related quality of life of said patients are improved while
medical costs are minimized. A patient population is first
identified. The population is then stratified into specific levels
of intervention. Each individual patient is then assigned a
Priority Care Nurse Manager who serves to establish communication
between the patient, the patient's Primary Care Physician, and any
healthcare providers. The most appropriate treatment plan is
cooperatively developed and the patient receives treatment
according to the plan. The most appropriate treatment may include
home care and palliative measures. The patient may appoint a Health
Care Agent to make medical decisions for the patient should the
patient be unable to make decisions.
Inventors: |
Thesman; Debra; (Garden
City, NY) |
Family ID: |
38369828 |
Appl. No.: |
13/439565 |
Filed: |
April 4, 2012 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13028557 |
Feb 16, 2011 |
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13439565 |
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12618582 |
Nov 13, 2009 |
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13028557 |
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11352028 |
Feb 10, 2006 |
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12618582 |
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Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 20/00 20180101;
G16H 40/67 20180101; G06Q 10/10 20130101; G16H 50/30 20180101; G16H
10/60 20180101; G16H 50/20 20180101 |
Class at
Publication: |
705/2 |
International
Class: |
G06Q 50/22 20120101
G06Q050/22 |
Claims
1. A method of administering healthcare to patients with multiple
integral diagnoses such that the clinical outcomes and
health-related quality of life of said patients are improved while
medical costs are minimized, the method comprising: a) identifying
a patient population entitled to receive said healthcare; b)
stratifying the patient population identified in step a) into
specific levels of intervention; c) assigning a Priority Care Nurse
Manager (PCNM) to each patient in said population; d) establishing
communication between the PCNM, the patient's Primary Care
Physician (PCP), and the patient to cooperatively develop the most
appropriate treatment plan that is available to the patient; and e)
rendering healthcare services according to the treatment plan
developed in step d) to the patient.
2. The method of claim 1 wherein said patients identified in step
a) are actively enrolled in a Health Maintenance Organization
(HMO), Medicare, or Medicaid.
3. The method of claim 1 wherein said patients identified in step
a) have ongoing needs to maintain optimal health status.
4. The method of claim 3 wherein said patients have a condition
selected from the group consisting of a chronic medical condition;
a recurring medical condition; multiple emergency room visits in
the previous year; functional or emotional impairments; a mental or
physical handicap or a developmental disability; a terminal
illness; an organ transplant; a pain management recipient;
dependency on medical, technological support; and multiple
surgeries or hospitalization in the previous year.
5. The method of claim 1 wherein said patients identified in step
a) have a specific condition requiring continuing treatment and
monitoring.
6. The method of claim 5 wherein said patients have a condition
selected from the group consisting of HIV/AIDS; cardiovascular
conditions; multiple trauma or neurological conditions; sick
neonates; obstetric conditions; and malignant cancer
conditions.
7. The method of claim 1 wherein the stratification in step b) is
based upon the severity of confirmed medical conditions of said
patients.
8. The method of claim 7 wherein the patient population is divided
into three specific groups.
9. The method of claim 1, wherein step d) further includes
communication with one or more of the people selected from the
group consisting of a specialist physician, a provider of
healthcare service, a patient's family member, and a patient's
designee.
10. The method of claim 1 wherein, upon the patient's consent, the
most appropriate treatment plan determined in step d) includes not
hospitalizing the patient.
11. The method of claim 10 wherein the treatment plan comprises
maintaining the patient at home, an assisted living facility, or a
hospice facility; forgoing aggressive life-continuing treatment;
and providing palliative care.
12. The method of claim 1 further comprising the step: f) the PCNM
periodically monitoring said patient's overall status, adherence to
the established treatment plan, and identifying any needed changes
in the treatment plan.
13. The method of claim 12 further comprising the step: g)
documenting all communications in step d), documenting all
healthcare services rendered in step e), and documenting the
results of all monitorings in step f).
14. The method of claim 1 further comprising the step: h) said
patient completing a Health Care Proxy, in which a Health Care
Agent is appointed to make medical decisions for said patient when
said patient is unable to make said medical decisions.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] The present application is a continuation of U.S. patent
application Ser. No. 13/028,557, filed Feb. 16, 2011, entitled
SYSTEM AND METHOD OF PRIORITIZING AND ADMINISTERING HEALTHCARE TO
PATIENTS HAVING MULTIPLE INTEGRAL DIAGNOSES, which is a
continuation of U.S. patent application Ser. No. 12/618,582, filed
Nov. 13, 2009, entitled SYSTEM AND METHOD OF PRIORITIZING AND
ADMINISTERING HEALTHCARE TO PATIENTS HAVING MULTIPLE INTEGRAL
DIAGNOSES, which is a continuation of U.S. patent application Ser.
No. 11/352,028, filed Feb. 10, 2006 entitled SYSTEM AND METHOD OF
PRIORITIZING AND ADMINISTERING HEALTHCARE TO PATIENTS HAVING
MULTIPLE INTEGRAL DIAGNOSES, all of the teachings of which are
incorporated herein by reference.
STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT
Not Applicable
BACKGROUND
[0002] The present invention is directed to systems and methods for
administering healthcare resources amongst patients within a
patient population. More particularly, the present invention
comprises systems and methods for prioritizing treatment of
patients having multiple integral diagnoses based on the severity
of confirmed medical conditions.
[0003] The ability to render high quality healthcare in a cost
effective manner is an elusive object that many healthcare plans
and providers have attempted but few have actually attained.
Despite substantial efforts made by healthcare plans, health
maintenance organizations (HMO), physician networks,
government-sponsored health care plans and the like, there is
lacking a system for facilitating healthcare treatment for patients
with multiple integral diagnoses, wherein the patients' quality of
life is improved while at the same time medical costs are minimized
in order to be able to provide the best care to the most
patients.
[0004] It is well known that patients with multiple integral
diagnoses face poor clinical outcomes and a low quality of life
that is further exacerbated by the patient not abiding by the
prescribed treatment plan. Also, many patients with multiple
integral diagnoses are not fully educated as to all of the options
available to them within their medical plan coverage and
accordingly do not avail themselves of all possibilities for
treatment of their conditions. Furthermore, under traditional
healthcare plans, different members of a patient's health care team
are often unaware of each other's activities and of the patient's
overall treatment plan. As such, oftentimes a patient with multiple
integral diagnoses that if carefully managed would be able to
vastly improve her clinical outcome and health-related quality of
life suffers due to lack of maintaining a developed treatment plan,
lack of education, and/or lack of healthcare team coordination.
Additionally, medical costs are often wasted due to this lack of
coordination and lack of educating the patient to all possibilities
for treatment causing an overall loss in funds available for
treatment of the entire patient population.
[0005] For example, many patients with multiple integral diagnoses
are unaware of the possibility of avoiding hospitalization and
extreme life sustaining treatments. It has been assumed that the
treatment of disease includes hospitalizing the patient and taking
all measures necessary in order to prolong the life of the patient,
irregardless of what that patient's quality of life will be.
Traditional healthcare plans often do not focus on what may be the
best option for the patient, or do not take the patient's desires
into consideration when reaching a medical treatment plan.
[0006] As such, there is a substantial need in the art for a
healthcare administration system and method that are operative to
effectively and efficiently utilize healthcare resources to
administer care to patients with multiple integral diagnoses. There
is further a need in the art for such a system and method that
serves to improve the patient's clinical outcome and quality of
life while minimizing medical expenses.
BRIEF SUMMARY
[0007] The present method is directed to methods of administering
healthcare to patients with multiple integral diagnoses such that
the clinical outcomes and health-related quality of life of the
patients are improved while medical costs are minimized. According
to a preferred embodiment, a patient population is first identified
which is entitled to receive such healthcare. The patient
population is then stratified into specific levels of intervention.
Each patient is then assigned a Priority Care Nurse Manager (PCNM).
The PCNM then establishes communication between herself, the
patient's Primary Care Physician (PCP), and the patient in order to
cooperatively develop the most appropriate treatment plan available
to the patient. Finally, the healthcare services determined by the
treatment plan are rendered to the patient.
[0008] The identified patients may be actively enrolled in a Health
Maintenance Organization (HMO), a governmental health program, or
some similar health plan. Patients enrolled in an HMO may be
commercial patients, Medicaid patients, or Medicare Advantage
patients. Governmental health programs may include Medicaid and
Medicare. Further, the identified patients may have ongoing needs
to maintain optimal health status. These ongoing needs may include
having a chronic medical condition, having a recurring medical
condition, having multiple emergency room visits within the
previous year, having functional or emotional impairments, having a
mental or physical handicap or a developmental disability, having a
terminal illness, being an organ transplant recipient, being a pain
management recipient, being dependent on medical, technological
support, or having multiple surgeries or hospitalization within the
previous year. Alternatively, the identified patients may have a
specific condition requiring continuing treatment and monitoring.
These specific conditions may include HIV/AIDS, cardiovascular
conditions, multiple traumas or neurological conditions, sick
neonates, obstetric conditions, or malignant cancerous
conditions.
[0009] The stratification into specific levels of intervention may
be based upon the severity of the patients' confirmed medical
conditions. The patient population may then be divided into three
specific groups based upon the confirmed severity.
[0010] The PCNM may further communicate with a specialist
physician, a provider of healthcare service, a patient's family
member, and/or a person designated by the patient. After receiving
the patient's consent, it may be determined that the most
appropriate treatment plan includes not hospitalizing the patient.
The treatment plan may further include maintaining the patient at
her home, an assisted living facility, or a hospice facility,
forgoing aggressive life-continuing treatment, and providing
palliative care.
[0011] The method may further include the PCNM periodically
contacting the patient. This contact may be used to determine the
patient's overall status, compliance with the established treatment
plan, and to identify any needed changes in the treatment plan.
[0012] The method may include documentation of all communications.
All healthcare services rendered may also be documented. Finally,
the results of all periodic contact with the patient may be
documented.
[0013] The method may also include the patient completing a Health
Care Proxy (HCP) form. The HCP form may be used to appoint a Health
Care Agent (HCA) who may make medical decisions for the patient in
situations where the patient is unable to make medical decisions
for herself.
BRIEF DESCRIPTION OF THE DRAWINGS
[0014] These and other features and advantages of the various
embodiments disclosed herein will be better understood with respect
to the following description and drawings, in which like numbers
refer to like parts throughout, and in which:
[0015] FIG. 1 is a flowchart depicting the steps for practicing the
present invention as it relates to administering healthcare to a
population of patients afflicted with multiple integral diagnoses,
including the development of the most appropriate treatment plan
for each patient with the aid of a Priority Care Nurse Manager.
DETAILED DESCRIPTION
[0016] The present invention is directed to methods of effectively
administering healthcare to patients with multiple integral
diagnoses. To this end, such patients are enrolled in a Priority
Care Management Program (PCMP). The goals of the PCMP are to
improve the patients' clinical outcomes and health-related quality
of life, while at the same time minimizing medical costs, by
increasing patient adherence to the physician established treatment
plan for the management of the patient's medical conditions. The
result is decreased numbers of avoidable hospitalizations,
decreased numbers of hospital readmissions, decreased numbers of
Emergency Room visits, decreased patient mortality, and improved
patient and physician satisfaction.
[0017] According to a preferred embodiment illustrated in FIG. 1, a
patient population is first identified in step 10 which will
receive this healthcare. The identification of such patient
population in step 10 may be achieved by identifying patients with
Multiple Integral Diagnoses (MID). Such patients are identified
with chronic conditions that if carefully managed will result in
improved clinical outcomes and medical cost savings. This may be
achieved by analyzing claims and referral utilization data to
identify patients that would qualify for the program. It is
contemplated that members eligible for participation in the PCMP
would be actively enrolled in a Health Maintenance Organization
(HMO), a governmental health program, or some similar medical plan.
In one embodiment, the PCMP would be completely voluntary and
provided to the patients at no additional charge above any premiums
they already pay to their individual medical plan.
[0018] Once identified in step 10, the patient population is
stratified into specific levels of member interventions in step 12.
This stratification is achieved by the Primary Care Physician's
(PCP) and/or specialty physician's evaluation of each patient in
order to determine the severity of each patient's confirmed medical
condition. In a preferred embodiment, the patient population is
stratified into three specific levels of member interventions based
upon identified need.
[0019] Patients in the first level of case management, Low
Intensity Care Management, will receive an assessment of their
utilization history; a follow-up assessment with patient/caregivers
regarding access to services, adherence to plan of care, safety,
knowledge deficits, and outcomes; patient education concerning a
review of health plan benefits, self-management skills, and
awareness of signs and symptoms of impending complications; a
coordinated plan of care with servicing providers; and
identification of community resources offered. Patients in the
second level of case management, Complex Care Management, will
receive all of the focused interventions of level one along with
intermittent assessments and follow-ups with patient/caregivers,
physicians, and/or ancillary providers regarding access to
services, adherence to plan of care, safety, knowledge deficits,
and outcomes, including identification of long-term and short-terms
goals; individualized and comprehensive assessment and evaluation;
and facilitation and coordination of safe, appropriate, high
quality, cost-effective care within the patient's health plan
benefit structure. Patients in the third level of case management,
High Intensity Care Management, will receive all of the focused
interventions of Level 1 and 2 along with frequent assessments and
follow-ups with patient/caregivers regarding access to services,
adherence to plan of care, safety issues, knowledge deficits, and
outcomes; and focused interventions utilizing innovative
possibilities to facilitate coordination of specialized needs with
an emphasis on achieving optimal outcome in the most efficient,
cost-effective manner.
[0020] Each patient is then assigned a Priority Care Nurse Manager
(PCNM) in step 14 who will oversee the patient's individual
treatment plan. The PCNM will contact the patient and/or family
members to introduce the program and will then establish contact
with the healthcare team treating the patient in regards to the
patient's medical status and treatment plan. The healthcare team
may consist of the PCP, physician specialists, and/or providers of
service. In step 16, the PCNM communicates and collaborates, as is
necessary, with the patient, the patient's physicians, the
patient's providers, the patient's family members, and/or anyone
designated by the patient in order to develop the most appropriate
treatment plan that is available to the patient. The PCNM will then
proceed in step 18 to coordinate and facilitate implementation of
all required services. In optional step 20, the PCNM may
periodically monitor the patient's overall status, adherence to the
established treatment plan and any needed changes in the treatment
plan in order to ensure that the patient is taking full advantage
of the healthcare benefits available under the patient's health
plan. All interactions involving the PCNM, any requests for
services, and all healthcare services actually rendered may be
documented by the PCNM in optional step 22. Priority Care Nurse
Management rounds may be conducted weekly in which patient files
will be reviewed by senior management with the PCNM in order to
determine that the optimal level of care is being used.
[0021] Patients eligible for participation in the PCMP may have
ongoing needs to maintain optimal health status, including but not
limited to chronic conditions; recurring medical conditions;
multiple emergency room visits, surgeries, or hospitalizations in
the prior year; functional or emotional impairments; mental,
physical, or developmental disablements; terminal illness; an organ
transplant recipient; a pain management patient; or being dependent
on medical, technological support (such as ventilator dependency).
Chronic conditions may include but are not limited to asthma,
congestive heart failure, chronic obstructive pulmonary disease,
diabetes, and end stage renal disease.
[0022] Alternatively or additionally, patients eligible for
participation in the PCMP may have specific conditions or
diagnoses, including but not limited to HIV/AIDS; cardiovascular
conditions; multiple trauma or neurological conditions; sick babies
or neonates; obstetric conditions; or malignant cancerous
conditions. HIV/AIDS may include but is not limited to HIV/AIDS
with Pneumocystis carinii pneumonia; HIV/AIDS with Kaposis Sarcoma;
or HIV/AIDS with pneumonia from an unspecified organism.
Cardiovascular conditions may include but are not limited to aortic
rupture, ruptured abdominal aneurysm, diseases of the aortic or
mitral valve, arrhythmias, atrial fibrillation, ventricular
fibrillation, paroxysmal atrial tachycardia, premature ventricular
contractions, tachycardia, bradycardia, cardiac arrest, cardiac
ischemia, coronary artery disease, endocarditis, perforated heart,
myocardial infarction, intractable angina, peripheral vascular
disease, or cardiac bypass surgery. Multiple trauma or neurological
conditions may include but are not limited to altered mental
status, brain aneurysm, brain tumor, paraplegia, quadriplegia,
multiple sclerosis, cerebral anoxia/hypoxemia, cerebral
atherosclerosis, coma, a cerebral vascular accident or hemorrhage,
a motor vehicle accident or multiple trauma, transient ischemic
attacks, unconsciousness, anoxic encephalopathy, hydrocephalus,
closed head injury, spinal cord injury, burns, frostbite,
amputations, meningitis, Reyes Syndrome, Guillian Barre, amyotropic
lateral sclerosis (ALS), Alzheimer's disease, or primary dementia.
The cerebral vascular accident or hemorrhage may include
intracerebral, intracranial, subdural or unspecified incidents. A
motor vehicle accident may include automobile versus motorcyclist,
pedestrian versus automobile, cardiac injury including cardiac
contusions, fractured skull, crush injuries, and shock. Sick babies
or neonates may include but are not limited to anemic newborns,
respiratory arrest (apnea newborns), premature births, birth
traumas, or congenital anomalies (major or multiple). Obstetric
conditions may include but are not limited to pregnancy with three
or more fetuses, bleeding during pregnancy, history of problem
births or sick babies, or toxemia during pregnancy which requires
hospitalization. Malignant cancerous conditions may include but are
not limited to unspecified cancers, brain cancers, bone metastasis,
colon cancer, esophageal cancer, kidney cancer, liver cancer, lung
cancer, ovarian cancer, prostate cancer, spinal cancer, stomach
cancer, leukemia, lymphatic cancer, aplastic anemia, lymphoma,
malignant leucopenia, unspecified metastasis, specified metastasis,
myeloma, or other conditions which require chemotherapy and/or
radiation therapy.
[0023] It is contemplated by this invention that in some situations
the most appropriate level of care for a patient identified in step
16 may be to avoid hospitalization. In this regard, the present
invention may include the utilization of a Do Not Resuscitate (DNR)
order and/or a Do Not Hospitalize (DNH) order. It is human nature
to want to send a sick person to the hospital; however, that may
not always be in the best interest of the patient. That does not
mean that the patient receives no care; rather, the focus of the
care is on providing relief from uncomfortable symptoms while at
the same time not unnecessarily prolonging what will be a short,
painful remainder of life. In some cases, the best possible care
determined in step 16 may include maintaining the patient at home,
in an assisted living facility, an inpatient skilled nursing
facility, or a hospice facility. In such cases, all efforts will be
made to keep the patient free of pain and allow for a peaceful
end.
[0024] Additionally, the present invention may include the
utilization of a living will and/or a Health Care Proxy (HCP). As
used herein, a living will means a document in which the patient
identifies the types of treatment the patient does and does not
desire in the case that the patient can no longer speak for
herself. As used herein, an HCP is a document wherein a patient
designates a Health Care Agent (HCA) who will make medical
decisions for the patient in the case that the patient is no longer
capable of making her own health care decisions. For the purposes
of this invention, a patient is no longer capable of making their
own medical decisions when the treating doctor determines that the
patient is no longer able to make such decisions and another
healthcare professional agrees that this is true. The HCA should be
at least eighteen years old, made aware of the patient's wishes,
and agree to respect and follow those wishes. A preferred HCA would
be someone who knows the patient very well, cares about the
patient, is capable of making difficult decisions, and is likely to
be nearby when decisions need to be made. Depending on each
patient's individual situation a spouse or family member may be the
best choice, or they may be too emotionally involved to be the best
choice. Regardless of whom the patient appoints as her HCA, it
should not be the patient's health care provider, an employee of
the patient's healthcare provider, or serving as an HCA for 10 or
more people unless he or she is your spouse or close relative.
[0025] The HCP is revocable by the patient at any time by
destroying all copies, informing his doctor or family that he
wishes to cancel or change his HCA, or writing the word "Revoked"
across the name of each agent he wants to cancel and signing that
page. The HCP may also include an expiration date after which it is
no longer valid. The HCA can make all medical decisions for the
patient, or the patient may define in the HCP which decisions may
be made by the HCA. The patient may also include specific
instructions in the HCP regarding certain medical treatments, if so
desired. These treatments may include, but are not limited to the
following items: artificial respiration, artificial nutrition and
hydration, cardiopulmonary resuscitation (CPR), antipsychotic
medication, electric shock therapy, antibiotics, surgical
procedures, dialysis, transplantations, blood transfusions,
abortion, and sterilization. For example, an HCP may include
directions that the patient does not want to be in pain so that the
doctor should deliver enough medicine to relieve the pain even if
the result is making the patient drowsier or sleepier than would
otherwise be the case; whether the patient does not want anything
done or omitted with the intention of taking your life; or that you
want to be offered food and fluids only by mouth and kept clean and
warm. The HCA must follow all directions made by the patient.
Certain benefits of appointing an HCA include allowing the agent to
make health care decisions on the patient's behalf as the patient
would want them decided, choosing one person to make the decisions
because the patient believes that person would make the best
decisions, and choosing one person to make the decisions in order
to avoid conflict or confusion between family members. An
alternative HCA may also be appointed in the HCP should the primary
HCA be unavailable, unable, or unwilling to make a decision. Also,
the HCP may include the patient's organ and tissue donation wishes,
including whether donations may be used for transplantation,
research, and/or educational purposes. However, the lack of
donation instructions in an HCP will not be taken to mean that the
patient does not want to be an organ/tissue donor.
[0026] The above description is given by way of example, and not
limitation. Given the above disclosure, one skilled in the art
could devise variations that are within the scope and spirit of the
invention disclosed herein. For example, it is contemplated that
invention as disclosed herein could readily be used and integrated
within those systems and methods disclosed in pending U.S. patent
application Ser. No. 10/615,640, filed Jun. 8, 2003, entitled
HEALTHCARE ADMINISTRATION METHOD; U.S. patent application Ser. No.
10/679,178, filed Oct. 3, 2003, entitled HEALTHCARE ADMINISTRATION
METHOD HAVING QUALITY ASSURANCE and U.S. patent application Ser.
No. 11/063,268, filed Feb. 22, 2005, entitled SYSTEMS AND METHODS
FOR ASSESSING AND OPTIMIZING HEALTHCARE ADMINISTRATION, the
teachings of all of which are expressly incorporated herein by
reference. Further, the various features of the embodiments
disclosed herein can be used alone, or in varying combinations with
each other and are not intended to be limited to the specific
combination described herein. Thus, the scope of the claims is not
to be limited by the illustrated embodiments.
* * * * *