Person-Centered Care Planning For People With Chronic Conditions Can Improve The Quality Of Care, But Challenges Exist

Systemic challenges currently limit the adoption of person-centered care plans (PCCP) for people with multiple chronic conditions (MCC), although PCCP is considered a promising approach for improving the quality of care for those with MCC. People with MCC often experience impaired access to care and needed services—care fragmentation and inadequate treatment—leading to suboptimal health outcomes and avoidable acute care utilization. Strategies to address the challenges include alignment of payment, policy support, health system culture change, and adoption of meaningful measures.

PCCPs define individualized care that meets the needs of the consumer, their families and caregivers, and their communities by maximizing consumer access, autonomy, and engagement. The focus is aligning care delivery with a person’s goals, preferences, and social context. It involves shared decision-making, addressing the consumer’s social needs (including language or cultural barriers), facilitating access to information and services, and delivering services in the home or community settings.

To improve the adoption of PCCP for people with MCC, strategies can include multidisciplinary teams, digital health technologies, and related workflow changes. The focus should be on coordinated care, prevention across the life course, and support for education and self-management. Payment policies should align with the person’s goals and support the goals of the payer, the health system, and the community.

Multidisciplinary team-based care is a key strategy for PCCP for coordinating or integrating health and social care across care settings. It requires the team members and provider organizations to create workflows (tools, practices, and technologies) to collaborate for dynamic shared care planning. It also requires information sharing with and by consumers. Digital health solutions could help prioritize the user experience, share data, stratify consumer risks, and provide remote monitoring.

Payment reforms needed to support PCCP should address currently insufficient and misaligned payment models and cover the costs of interdisciplinary teams. Value-based payment models could focus on outcomes related to the prevention or slowing of functional decline. To engage consumers in PCCP and self-management, the burden of out-of-pocket costs could be eliminated for care planning and management services.

Aligning community, health system, and payer goals can result in meaningful measures to assess the quality of person-centered care while distributing resources more equitably. The use of aligned measures can drive improvements and contribute to demonstrating and documenting return on investment.

These findings were reported in “Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions” by Brittany N. Watson, M.D., MPH; Lilly Estenson, MSW; Aimee R. Eden, Ph.D., MPH; with senior author Arlene S. Bierman, M.D., MS, and colleagues. The researchers reviewed responses from a request for information (RFI) published in the Federal Register soliciting input on PCCP, posted by the Agency for Healthcare Research and Quality in 2022. The RFI posed 27 questions. The qualitative analysis focused on identifying themes across the responses, although none of the 58 respondents answered all the questions. The responses were submitted by individuals and organizations who identified as, provided care for, or sought to improve care for individuals living with or at risk for MCC.

For more information, contact: Brittany N. Watson, M.D., MPH, Clinical Assistant Professor, Department of Family and Community Medicine, Wake Forest University School of Medicine, 1920 West First Street, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina 27104; Email: brnwatso@wakehealth.edu; Website: https://school.wakehealth.edu/faculty/w/brittany-n-watson