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

Abstract

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.

Keywords: multimorbidity; older adults; patient priorities; practice change.

Conflict of interest statement

Conflict of Interest: The authors declare that they have no competing interests.

© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Figures

Figure 1.

Conceptual model to guide patient priorities based clinical decision-making for older adults. The number of people in each of these 3 groups may vary depending on the population and the specific comorbidities or advanced disease. The model is intended to demonstrate that there is a substantial group of older adults (uncertain) for whom guideline-driven care or advanced disease care is of uncertain benefit or not appropriate.

Figure 2.

In the primary care provider (PCP) office, eligible patients are identified, the PCP invites them, and they are given a facilitator appointment. Facilitators guide patients in developing priorities and filling out a priorities template for the electronic health record (EHR). The patient returns to the PCP at a regular or special visit and discusses priorities. PCP and patient work to align care with priorities. Facilitator then follows up with patient to reinforce priorities. The primary care and cardiology offices communicate regarding PPC patients to ensure patients are flagged in cardiology EHR and that the cardiologist has referral, priorities template, and PCP note. Cardiologist discusses priorities and works to align care with patient priorities. Cardiologist and PCP communicate.