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Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions
Brittany N Watson1, Lilly Estenson2, Aimee R Eden3
1Department of Family and Community Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina.
JAMA Network Open
|October 17, 2024
Summary
Person-centered care planning (PCCP) addresses the needs of individuals with multiple chronic conditions (MCC). Strategies and barriers to implementing PCCP were identified to improve care quality and value.
Area of Science:
- Health Services Research
- Patient-Centered Care
- Chronic Disease Management
Background:
- The US faces a growing population with multiple chronic conditions (MCC), yet the healthcare system struggles to meet their complex needs.
- Person-centered care planning (PCCP) is a vital approach to tailor comprehensive care, aiming to improve health outcomes and healthcare value.
- Existing systems often lack the design and integration necessary for effective PCCP delivery to individuals with MCC.
Purpose of the Study:
- To identify strategies for delivering PCCP to individuals with or at risk for MCC.
- To explore the facilitators and barriers associated with the implementation of PCCP.
- To inform future research and implementation efforts for widespread PCCP adoption.
Main Methods:
- A qualitative study employing thematic analysis of responses to a Request for Information (RFI) from the Agency for Healthcare Research and Quality (AHRQ).
- The RFI, open for public comment in late 2022, solicited input on PCCP from diverse stakeholders.
- Analysis involved inductive and deductive coding of open-text responses from 58 respondents, including patients, caregivers, clinicians, and organizational representatives.
Main Results:
- Nine key themes emerged: suboptimal care quality, the importance of person-centered and goal-concordant care, multidisciplinary team-based care and coordination, and life-course prevention.
- Additional themes included digital health solutions, workflow integration, education and self-management support, payment models, and aligning community, health system, and payer goals.
- Identified challenges to PCCP adoption include payment alignment, policy support, culture change, and the need for meaningful quality measures.
Conclusions:
- Widespread adoption of PCCP faces challenges requiring strategic solutions, including payment reform, policy adjustments, and cultural shifts within healthcare systems.
- Developing and disseminating evidence-based strategies for scaling and spreading PCCP are crucial for its successful integration into routine care.
- The findings provide valuable insights for prioritizing research and guiding implementation initiatives to advance PCCP for individuals with MCC.
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