Perspectives of Patients, Clinicians, and Health System Leaders on Changes Needed to Improve the Health Care and Outcomes of Older Adults With Multiple Chronic Conditions

Ferris, Rosie; Blaum, Caroline S.; Kiwak, Eliza; Austin, Janet; Esterson, Jessica; Harkless, Gene; Oftedahl, Gary; Parchman, Michael L.; Ness, Peter H. Van; Tinetti, Mary E.

doi:10.1177/0898264317691166

Cited by 47 publications

(59 citation statements)

References 37 publications

(52 reference statements)

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“…5 A national group of primary care and specialty clinicians (physicians and nurses), patients and caregivers, researchers, healthcare system representatives, health information technology (HIT) experts, healthcare redesign engineers, and payers designed a healthcare prototype to address these problems. 6,7 This prototype, Patient Priorities Care (PPC), calls upon patients and caregivers to articulate their health priorities with the guidance of a trained member of the healthcare team, which are then communicated to all team members; patients, caregivers, and clinicians together choose the health care best aligned with these health priorities. 6 Health priorities are defined as the patient's health outcome goals-what they want from their healthcare-and their healthcare preferences-the healthcare activities they are able and willing to perform.…”

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confidence: 99%

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

Blaum

Rosen

Naik

et al. 2018

J American Geriatrics Society

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110

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Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan‐do‐study‐act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision‐making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision‐making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision‐making challenges. Translating disease‐based to priorities‐aligned decision‐making appears challenging but feasible to implement in a clinical setting.

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confidence: 99%

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

Blaum

Rosen

Naik

et al. 2018

J American Geriatrics Society

Self Cite

110

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“…In daily medical practice, multimorbidity challenges decision making in several ways. Disease priorities can be interfering and the need of adherence to multiple disease guidelines can be problematic . Disease‐specific guidelines are often not applicable to older patients with multiple conditions and compliance to multiple single disease guidelines can result in polypharmacy, high treatment burden, inattention to social and personal context and failure to align care with personal goals and preferences .…”

Section: Introductionmentioning

confidence: 99%

A three‐goal model for patients with multimorbidity: A qualitative approach

Vermunt

Harmsen

Elwyn

et al. 2017

Health Expectations

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BackgroundTo meet the challenge of multimorbidity in decision making, a switch from a disease‐oriented to a goal‐oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed.ObjectiveThis study aimed to develop conceptual descriptions of goal‐oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity.MethodQualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis.ResultsClinicians distinguished disease‐ or symptom‐specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. “Fundamental goals” are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations.ConclusionBased on the perspectives of clinicians, we expanded the concept of goal‐oriented care by identifying a three‐level goal hierarchy. This model could facilitate collaborative goal‐setting for patients with multiple long‐term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.

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“…During a follow‐up visit, patients, caregivers, and clinicians then collaboratively make healthcare decisions that align with these patient health priorities. This values‐based decisional process is referred to as Patient Priorities Care (PPC) …”

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confidence: 99%

“…This values-based decisional process is referred to as Patient Priorities Care (PPC). 13,14 We previously described the development, refinement, and implementation of PPC and of the Patient Health Priorities Identification (PHPI) process component, the first step in PPC. [13][14][15] We then sought to solicit patient perspectives of the PHPI to iteratively improve the process for future work and applications.…”

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confidence: 99%

“…13,14 We previously described the development, refinement, and implementation of PPC and of the Patient Health Priorities Identification (PHPI) process component, the first step in PPC. [13][14][15] We then sought to solicit patient perspectives of the PHPI to iteratively improve the process for future work and applications. Therefore, the purpose of this qualitative study was to describe patients' perceptions of the PHPI process, identify enabling factors and barriers to the process, and elicit recommendations from patients on process enhancement.…”

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confidence: 99%

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Perspectives of Patients in Identifying Their Values‐Based Health Priorities

Feder

Kiwak

Costello

et al. 2019

J American Geriatrics Society

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OBJECTIVES Patient Health Priorities Identification (PHPI) is a values‐based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients’ perceptions of PHPI. DESIGN Qualitative study using thematic analysis. SETTING In‐depth semistructured telephone and in‐person interviews. PARTICIPANTS Twenty‐two older adults who participated in the PHPI process. MEASUREMENTS Open‐ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. RESULTS Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15–26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow‐up, and the inclusion of health‐related tasks in facilitation visits. CONCLUSIONS Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values‐based priorities.

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Perspectives of Patients, Clinicians, and Health System Leaders on Changes Needed to Improve the Health Care and Outcomes of Older Adults With Multiple Chronic Conditions

Abstract: Stakeholders' recommendations suggest health care redesigns that incorporate patients' health priorities into care decisions and realign relationships across patients and clinicians.

Cited by 47 publications

References 37 publications

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

A three‐goal model for patients with multimorbidity: A qualitative approach

Perspectives of Patients in Identifying Their Values‐Based Health Priorities

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