Continuous Health Care Plan Coordination Between Patient and Patient Care Team

摘要

Mechanisms are provided for implementing a personalized health care management system. The mechanisms receive a personalized health care plan for a patient having at least one health goal of the patient, and dynamic patient monitoring data from one or more patient monitoring devices associated with the patient. The mechanisms analyze the dynamic patient monitoring data to determine at least one first communication to output to the patient containing content eliciting conformance of the patient with the personalized health care plan to achieve the at least one health goal. The mechanisms send, to a patient care manager computing device of a patient care manager associated with the patient, a second communication based on results of analyzing the dynamic patient monitoring data. The second communication initiates a new communication session, or continues an existing communication session, between the patient care manager computing device and a patient communication device associated with the patient.