Abstract: Systems and methods for patient healthcare plan optimization. An optimization system includes a user interface, an optimizer and an influencer system. The user interface receives data including multi-factor determinants of a patient and a plurality of treatment personnel. The multi-factor determinants include at least one of clinical, behavioral, psychosocial, organizational and economic characteristics. The optimizer generates an electronic patient journey plan for the patient, by identifying one or more personnel among the treatment personnel to form a care team, roles for each selected personnel of the care team and actions for each of the care team and the patient, based on optimization of the multi-factor determinants of the patient and the treatment personnel according to one or more optimization algorithms. The influencer system determines software influencer instructions to be performed by designated influencers based on the electronic patient journey plan.

Abstract: Systems and methods for patient healthcare plan optimization. An optimization system includes a user interface, an optimizer and an influencer system. The user interface receives data including multi-factor determinants of a patient and a plurality of treatment personnel. The multi-factor determinants include at least one of clinical, behavioral, psychosocial, organizational and economic characteristics. The optimizer generates an electronic patient journey plan for the patient, by identifying one or more personnel among the treatment personnel to form a care team, roles for each selected personnel of the care team and actions for each of the care team and the patient, based on optimization of the multi-factor determinants of the patient and the treatment personnel according to one or more optimization algorithms. The influencer system determines software influencer instructions to be performed by designated influencers based on the electronic patient journey plan.

Abstract: The systems and methods are provided to enable consistent lifestyle modifications for chronic disease management. More specifically, systems and methods are directed to performing subjective health assessments (HAs) and objective stage-of-change (SOC) status evaluations of a patient's health based on data collected from the patient. These data are collected directly from the patient via the Internet and/or portable communications devices and maintained electronically for easy access by both the patient and health care providers.