Systems and methods for determining functionality of dialysis patients for assessing parameters and timing of palliative and/or hospice care

A method for determining a functionality level of dialysis patients for assessing parameters and timing of care, the method comprising:

• monitoring a patient;
• recording one or more patient parameters of the monitored patient;
• transmitting the one or more patient parameters to one or more databases within an integrated care system;
• analyzing the one or more patient parameters via one or more algorithms for determining a patient's functional status score;
• assessing that the patient's functional status score is below a predetermined threshold value and/or that the patient's functional status score is trending downwards;
• and
• providing one or more treatment plans including commencing one of an interventional treatment plan, or commencing palliative and/or hospice care, or combinations thereof.

A system for determining a functionality level of dialysis patients for assessing parameters and timing of care, the system comprising:

• an integrated care system configured to:
• extract patient data from one or databases corresponding to a pool of patients having end stage renal disease (ESRD);
• using a predictive model with the extracted patient data to generate, for each of the patients in the pool of patients, a respective patient functional status score;
• identify a subset of the pool of patients having a respective patient functional status score that is lower than a predetermined threshold value and/or a patient functional status score that is trending downwards;
• and
• based on the identified subset of the pool of patients, provide one or more treatment plans, wherein the treatment plans include at least one of (a) commencing one of an interventional treatment plan, or (b) commencing palliative and/or hospice care, or (c) combinations thereof.