Patient-centered plan-of-care tool for improving clinical outcomes

In developing our Patient-Centered Team Care (PCTC) program, we designed a Plan-of-Care (POC) tool to facilitate the physician-patient discussion for setting health goals. This study aimed to determine the effectiveness of the POC tool in improving clinical outcomes.

We compared baseline and 6-month or greater follow-up values for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SP), diastolic blood pressure (DP), and weight for PCTC patients (intervention group) and non-PCTC patients (control group). For the intervention group, we also compared POC tool completeness scores (1, low and 8, high).

Of 1366 patients, 1110 (593 intervention, 517 control) had baseline and follow-up clinical measures for analysis. After adjusting for demographics, significant effects occurred in the intervention group for HbA1c (P = .0067), LDL (P = .012), and DP (P = .091). For completeness of POC, a significant association occurred between more fully completed forms (scores, 5-8) and change in HbA1c (P < .001) and SP (P = .011).

Patients receiving a POC showed significant improvement in 3 of 5 clinical outcomes compared with those without the tool, and those with more fully completed forms had significant improvement in 2 of 5 clinical outcomes compared with those with partially completed forms.