IBD Care Coordination via Resilience Scoring
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Solution Overview
Problem
Current treatment regimens for inflammatory bowel disease (IBD) fail patients, particularly children, due to difficulties in transitioning from pediatric to adult healthcare and high rates of provider changes, leading to delayed or interrupted treatments, increased hospitalizations, and mental health concerns, with a significant burden on both patients and the medical system.
Innovation Solution
A system and method for evaluating patients with IBD to determine personalized and coordinated care plans based on resilience scores, using a combination of resilience domain assessments and IBD severity scores to categorize patients and tailor care plans, including enrollment in resilience programs, disease monitoring, and application of digital health tools.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If current treatment regimens are used for IBD patients, then standard care is provided, but patient outcomes deteriorate due to treatment interruptions and provider changes
Solution Approach 1:
A care coordination program acts as an intermediary between IBD patients and the healthcare system, managing treatment continuity across provider transitions. The program coordinates care plans, medication management, and follow-up appointments, ensuring uninterrupted treatment even when patients change specialists or transition from pediatric to adult care.
Solution Approach 2:
The system implements continuous feedback mechanisms by monitoring patient outcomes, treatment adherence, and provider interactions. This feedback loop enables real-time adjustments to care plans, early detection of treatment interruptions, and proactive management of patients at risk of discontinuing care.
2Reliability
If personalized care plans based on resilience scores are implemented, then patient outcomes improve, but system complexity increases
Solution Approach 1:
The system introduces resilience scoring as a new parameter for patient evaluation, transforming qualitative aspects of patient capacity into quantitative metrics. By measuring resilience across multiple domains (emotional, social, practical), the system creates actionable parameters that guide personalized care plan development and provider matching decisions.
Solution Approach 2:
The evaluation system segments patients into distinct categories based on their resilience scores and care needs. This segmentation enables tailored intervention strategies for different patient groups, such as intensive support for low-resilience patients and maintenance care for high-resilience patients, improving outcomes while managing system complexity through standardized protocols.
3Adaptability or versatility
If comprehensive resilience domain assessments are conducted, then care plan personalization improves, but time and resource consumption increase
Solution Approach 1:
Resilience assessments are conducted early in the patient-provider relationship, before critical treatment decisions must be made. This preliminary action establishes a baseline understanding of patient capacity and preferences, enabling personalized care planning without delaying essential medical interventions or treatment initiation.
Solution Approach 2:
The system implements tiered assessment approaches where not all patients receive the full comprehensive evaluation. Low-resilience patients or those with complex needs receive complete multi-domain assessments, while stable high-resilience patients receive streamlined assessments focusing on key domains, reducing overall time and resource consumption while maintaining personalized care where most needed.
Data Source
AI summary
Systems and methods are provided for evaluating a subject for inflammatory bowel disease (IBD) care coordination strategy. A resilience score is determined based on a plurality of different resilience domain assessments of the subject. When the resilience score satisfies a care coordination threshold, the subject is enlisted in an IBD care coordination program. An IBD severity score for the subject is determined based, at least in part, on one or more risk factors. Both the resilience score and the IBD severity score are used to assign the subject to a category in a plurality of categories. At least one time-limited care plan is determined at a first time for the subject based upon the identity of the assigned category. The at least one time-limited care plan is prioritized by an outcome of one or more resilience domain assessments in the plurality of different resilience domain assessments.