Abstract: The present disclosure pertains to a system for providing model-based predictions of actively managed patients. In some embodiments, the system (i) obtains a collection of information related to a payer-attributed population of patients associated with a provider; (ii) extracts, from the collection of information, health insurance claims data, clinical data, process data, and patient encounter data; (iii) provides the health insurance claims data, clinical data, process data, and patient encounter data to a machine learning model to train the machine learning model; (iv) causes the machine learning model to predict familiarity values associated with patients of the population of patients; and (v) generates a provider assessment based on the familiarity values and the collection of information.

Abstract: A system and method for guideline-based discharge planning of a patient from a facility, comprising determining via a processor whether a patient meets predetermined discharge criteria from the facility, generating a first signal indicative of the patient's risk of re-admission to the facility, generating a second signal indicative of a plan for providing care for the patient, generating a third signal indicative of a status of the patient for a post-discharge care report, and generating a fourth signal indicative of instructions to discharge the patient from the facility.

Abstract: There is provided a computer-implemented method (100) for generating a patient care plan. The method comprises acquiring (102) a plurality of single-condition care plans for a patient suffering from multiple medical conditions; enriching (104) at least one of the single-condition care plans; combining (106) the plurality of single-condition care plans into a multiple-condition care plan; and evaluating (108) a quality of the multiple-condition care plan relative to the plurality of single-condition care plans. A computer program product, an apparatus and a system are also disclosed.

Abstract: A computer-implemented method of manufacturing a computer-readable storage medium for a remote patient management system with instructions for causing the execution of a care plan comprising a coaching plan. The method comprises: displaying a list of psychological determinants, receiving a selection of a group of psychological determinants chosen from the list of psychological determinants, generating a list of behavioral models using the group of psychological determinants, receiving a selection of at least one selected behavioral model from the list of behavioral models, determining a time line for the global structure of the coaching plan using the at least one selected behavioral model, compiling a coaching object file using the time line, linking the coaching object file to a library of multi-media content to resolve unresolved symbolic links of the time line, integrating the coaching plan into the care plan, and writing the care plan to the computer-readable storage medium.

Abstract: A remote patient management system comprising a display and a processor. Execution of instructions cause the processor to: determine at least one first boundary value between a safe zone and a warning zone for each of at least one patient vital sign; determine at least one second boundary value between the warning zone and an alert zone for each of the at least one patient vital sign; repeatedly receive the at least one patient vital sign; determine a status value indicating the safe zone, warning zone, or alert zone; calculate a transition risk value; and display a patient status indicator which indicates the status level and the transition risk.

Abstract: A non-transitory computer-readable storage medium storing a set of instructions executable by a processor. The set of instructions is operable to receive a set of data relating to a current symptom of a patient; determine one of a current level of breathlessness and a current level of edema for the patient based on the received data; and provide an alert to one of the patient and a medical professional, if the determined one of the current level of breathlessness and the current level of edema is greater than an acceptable level.

Abstract: A healthcare support system for determining care for a patient and a corresponding healthcare support method are presented. The healthcare support system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining patient data, assessing a clinical need of the patient, proposing a clinical outcome, and determining a service to be provided to the patient for said clinical need and said proposed clinical outcome based on a service-outcome-need model. Further, the present invention relates to a computer-readable non-transitory storage medium and a computer program.

Abstract: A remote patient management system comprising a display and a processor. Execution of instructions cause the processor to: determine at least one first boundary value between a safe zone and a warning zone for each of at least one patient vital sign; determine at least one second boundary value between the warning zone and an alert zone for each of the at least one patient vital sign; repeatedly receive the at least one patient vital sign; determine a status value indicating the safe zone, warning zone, or alert zone; calculate a transition risk value; and display a patient status indicator which indicates the status level and the transition risk.

Abstract: A remote patient management system comprising a display and a processor. Execution of instructions cause the processor to: determine at least one first boundary value between a safe zone and a warning zone for each of at least one patient vital sign; determine at least one second boundary value between the warning zone and an alert zone for each of the at least one patient vital sign; repeatedly receive the at least one patient vital sign; determine a status value indicating the safe zone, warning zone, or alert zone; calculate a transition risk value; and display a patient status indicator which indicates the status level and the transition risk.

Abstract: A system (1) is described for providing a schedule comprising a plurality of instruction items. An assessment unit (2) determines at least one target behavior based on a health record (3), e.g. an electronic health record (EHR) of a patient. An information unit (4) determines a plurality of instruction items based on said at least one target behavior. Furthermore, the information unit (4) associates a first instruction item of the plurality of instruction items with a time duration. A scheduling unit (5) schedules the plurality of instruction items and determines a first presentation time for the first instruction item and a second presentation time for a second instruction item of the plurality of instruction items in dependence on a time period that starts at the first presentation time and has a time duration associated with the first instruction item.

Abstract: The present invention relates to a healthcare system and a corresponding healthcare method. The system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining patient activity data descriptive of a physical activity of a patient, for whom a recommendation for a care plan shall be provided, obtaining social support activity data descriptive of a level of interaction of the patient's social network with the patient, and computing recommendations for a care plan for the patient based on the patient activity data and the social support activity data. Further, the present invention relates to a computer-readable non-transitory storage medium and a computer program.

Abstract: The present invention relates to a clinical support system and a corresponding clinical support method. The system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining current patient data descriptive of a patient, for whom a recommendation for a transition from a current care levels to one or more other care levels shall be provided, in the current care level, obtaining historic patient data of the patient obtained earlier in the current and/or other care levels.

Abstract: A healthcare support system and healthcare support method for scheduling a clinical visit of a patient are presented. The healthcare support system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining clinical patient data descriptive of a clinical condition of the patient, obtaining psycho-social-assessment data of the patient, and scheduling a clinical visit for the patient based on said clinical patient data and said psycho-social-assessment data. Further, the present invention relates to a computer-readable non-transitory storage medium and a computer program. The proposed system assists in determining the need of a clinical visit, the urgency of a clinical visit and the nature of this visit in terms of required procedures and tests, topics to be discussed and professionals to be seen.

Abstract: A healthcare support system for determining care for a patient and a corresponding healthcare support method are presented. The healthcare support system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining patient data, assessing a clinical need of the patient, proposing a clinical outcome, and determining a service to be provided to the patient for said clinical need and said proposed clinical outcome based on a service-outcome-need model. Further, the present invention relates to a computer-readable non-transitory storage medium and a computer program.

Abstract: The exemplary embodiments are related to systems and methods for reducing early readmission according to an exemplary embodiment described herein. One embodiment relates to a method comprising receiving patient data for a patient; creating a personalized risk model for the patient based on the patient data, the personalized risk model including an overall risk level based on a plurality of risk factors; selecting one of the risk factors; administering treatment relating to the selected risk factor; updating the personalized risk model after administering treatment, the updating including determining an updated risk level; determining whether the updated risk level is above a threshold level; and repeating the selecting, administering, updating and determining steps if the risk level is above the threshold level.

Abstract: The exemplary embodiments are related to systems and methods for prioritizing risk models and suggesting services tailored to a patient profile according to an exemplary embodiment described herein. One embodiment relates to a method comprising retrieving risk model and parameter data from a risk database, retrieving hospital profile data from a records database, determining a recommendation value for the model and parameter data based on the hospital profile data, determining at least one recommended service for a patient based on the recommendation value, and outputting the at least one recommended service to a user.

Abstract: The present invention relates to a clinical support system and a corresponding clinical support method. The system comprises a processor and a computer-readable storage medium, wherein the computer-readable storage medium contains instructions for execution by the processor, wherein the instructions cause the processor to perform the steps of obtaining a health score curve over time of a patient, for whom a recommendation for a moment of discharge from a medical facility shall be provided, obtaining a reference curve to the health score curve, wherein said reference curve indicates a patient stabilization over time, computing a difference between the health score curve and said reference curve, and computing a recommended moment of discharge from the medical facility based on the difference between said health score curve and said reference curve. Further, the present invention relates to a computer-readable non-transitory storage medium and a computer program.

Abstract: A remote patient management system comprising a display and a processor. Execution of instructions cause the processor to: determine at least one first boundary value between a safe zone and a warning zone for each of at least one patient vital sign; determine at least one second boundary value between the warning zone and an alert zone for each of the at least one patient vital sign; repeatedly receive the at least one patient vital sign; determine a status value indicating the safe zone, warning zone, or alert zone; calculate a transition risk value; and display a patient status indicator which indicates the status level and the transition risk.

Abstract: A non-transitory computer-readable storage medium storing a set of instructions executable by a processor. The set of instructions is operable to receive a set of data relating to a current symptom of a patient; determine one of a current level of breathlessness and a current level of edema for the patient based on the received data; and provide an alert to one of the patient and a medical professional, if the determined one of the current level of breathlessness and the current level of edema is greater than an acceptable level.

Abstract: A system and method for guideline-based discharge planning of a patient from a facility, comprising determining via a processor whether a patient meets predetermined discharge criteria from the facility, generating a first signal indicative of the patient's risk of re-admission to the facility, generating a second signal indicative of a plan for providing care for the patient, generating a third signal indicative of a status of the patient for a post-discharge care report, and generating a fourth signal indicative of instructions to discharge the patient from the facility.