A Clinical Pathway to Well-Being: Putting Patient Priorities at the Center of Care

ABSTRACT

Patient Priorities Care is a clinical framework designed to align primary and specialty care around each individual patient’s goals. Using a patient’s self-defined goals can be a powerful motivator for improving health outcomes. Our experience with this approach on a population of nearly 124,000 Medicare Advantage patients after 1 year indicates that this model of care is generating substantial improvements in clinical outcomes for patients with type 2 diabetes, congestive heart failure, and hypertension.

The American Journal of Accountable Care. 2023;11(3):37-40. https://doi.org/10.37765/ajac.2023.89437

The goal of primary care is to help patients live longer, healthier, and higher-quality lives. This leads primary care clinicians to often focus on objective disease outcomes and biomarkers such as hemoglobin A1c levels, blood pressure, or body mass index. When working in a system that mostly ascribes value to disease metrics, it’s difficult for clinicians to practice medicine in a way that prioritizes patient-defined goals and holistic health.¹

One approach gaining momentum is appropriately named Patient Priorities Care (PPC).² PPC is a clinical framework designed to align primary and specialty care around each patient’s health prioritiesso that their individual values and preferences guide all aspects of their health care, supporting realistic health and life goals.

The PPC paradigm is designed for the specific needs of an aging population with multiple chronic conditions.³ This population faces some of the most complex health care challenges and drives most of the health care spending in the United States—with some estimates suggesting that 10% of the patient population accounts for nearly two-thirds of total costs. Implementing a person-centered approach not only helps drive toward the purpose, connection, and belonging essential to overall well-being, but also drives faster, better results across the baseline clinical markers that are foundational for health.⁴

Comprehensive care management (CCM) models have been widely implemented for chronically ill patients to help them and their caregivers better manage their medical and psychosocial conditions.⁵ These programs seek to improve patient self-reported outcomes and avoid unnecessary medical services, but results to date for CCM are mixed.^6-8 One reason may be that patients of this complexity often have too many problems to solve, so patients sometimes lose momentum in a sea of care plan elements that can be overwhelming.

The primary perspective that PPC adds, beyond a typical CCM model, is that it may ignore key medical issues if they are not related to the patient’s priority. This is anathema to many clinicians, but truly focusing on only what matters to the patient—at least at first—builds connection and trust and engages the patient in taking the practical health-related steps toward their goal. Building momentum in this way brings a therapeutic alliance well beyond the achievement of these early practical steps toward real progress on multiple goals, including, in many cases, those that are beyond the patient’s initial priority.

In practice, providers using PPC make an initial effort to understand what motivates each patient and their goals. That sounds simple, but clinical training ingrains a mental model of identifying problems, tying them to a diagnosis, and creating a treatment plan without thoughtful consideration of how the resulting plan aligns with a patient’s ability or willingness to adhere to the plan. Providers and patients are left speaking different languages, leading to confusion among patients, lower adherence to treatment and medications, and poorer outcomes.

If you ask a patient what they most hope to accomplish this month, it probably won’t be lowering their systolic blood pressure by 5 to 10 mm Hg. They are much more likely to say “being able to dance on my wedding anniversary” or even just “feeling well enough to go to the grocery store.” Linking the ability to achieve those goals to the steps required to lower their blood pressure helps activate the patient in a new way and engage them in their health on terms that matter to them.

Putting PPC Into Practice

To date, most of the work around PPC has been foundational, either done at the academic level or in targeted pilots with small populations and/or isolated settings.⁹ The next step is bringing this model of care to scale in commercial settings so that it becomes integrated into the delivery system and can drive improved outcomes at the population level.

Devoted Medical, which provides virtual and in-home advanced primary care services to support patients supplementary to their existing primary care practices, has successfully implemented this model of care across 13 states and a population of nearly 124,000 Medicare Advantage members. This represents one of the first examples of a large-scale commercial application of PPC, and the model is instructive for how to maximize the power of this clinical framework. The results to date suggest that the costs and challenges of implementing PPC are more than offset by the efficacy of this approach to care, high patient satisfaction, and meaningful improvements in clinical outcomes.

All longitudinal clinical care delivered through Devoted Medical is guided by patient priorities. The top care priority articulated by the patient is identified and translated into “The One Thing,” the core goal driving all care decisions. For example, in Devoted’s interdisciplinary home-based care model, a community health worker (CHW) performs an in-home visit to build on established trust with the goal of identifying a patient’s One Thing using the PPC framework. The CHW first identifies the patient’s values and then works with the patient to set SMART (specific, measurable, attainable, realistic, and time-bound) health outcome goals. Health care preferences, such as what care is helpful or burdensome, are identified. The conversation is summarized with the identification of The One Thing, which is the health problem or concern that the patient wants the health care team to address so that they can achieve the health outcome goal. Next, the nurse practitioner uses The One Thing as a communication tool and a decision guide to create a care plan aligned with the patient’s stated priorities. The ultimate output is a 6-month care plan designed to track toward the patient’s One Thing. To the extent that meaningful health care should seek to enable behavioral change, we believe this is only achievable when the changes will advance the patient’s core values.

Implementing the PPC framework is enabled by modifying electronic health record workflows. The most impactful changes are tracking patient priorities and progress toward achieving these priorities and creating a system for assigning tasks across the care team. For example, for patients with congestive heart failure, the provider will be prompted to collect both baseline and current weight, determine whether the patient has a scale, send the patient an LTE cellular network–enabled scale if needed, and identify whether the patient understands how and when to weigh themselves. These elements are often overlooked in routine documentation but are critical to understanding the current state and trajectory of the patient’s health, considering that weight gain can be an early indication of a heart failure exacerbation.

This combination of using the PPC model with an integrated care team and the technology to support new workflows is producing significant results for the patients. Devoted Medical’s internal data as of May 2023 reveal the following findings:

• Diabetes management program graduates have seen a mean per-member reduction in hemoglobin A1c of 2.1% in 83 days.
• Hypertension management program graduates have seen a mean per-member reduction in systolic blood pressure of 15.2 mm Hg in 40 days.
• Congestive heart failure management program enrollees have seen a 37% reduction in acute events after only 1 month, and only 1.8% of patients have had a subsequent acute event.
• Enrollees in the Intensive Home Care program, the home-based complex care model, showed a mean reduction in acute events and medical costs of more than 20% from the baseline 6 months prior to enrollment to the 12 months following.

The costs of PPC are chiefly that this model of care is time and resource intensive and only works if the providers delivering care have the training, time, and space to build trust with their patients. By having lower-cost resources such as CHWs invest the greatest share of time in eliciting and documenting PPC, these costs are partially mitigated but are somewhat offset by all staff spending additional time centering care on PPC. PPC also requires a fixed investment in technological infrastructure, usually in the form of modification to an electronic health record system, to support documentation and ongoing monitoring of the patient’s priorities by all staff members. Although these costs may add slightly to the per-member cost of a care management program, the benefits of a higher success rate on the various clinical metrics noted above far outweigh the marginally higher cost of delivering care using PPC, given how costly the care for these patients can be.

This initial evidence suggests that implementing the PPC clinical framework in a commercial setting can achieve the vision of reengineering care systems around older adults’ priorities and, in so doing, results in better health outcomes. Applying this more broadly across American health care may require continued expansion of value-based care models, design and implementation of technological systems that can support value-based care and patient-reported outcomes, and the adoption of care teams that can address patients’ unique clinical and nonclinical needs. If the US health care system makes the commitment to invest in this clinical model, we believe that it is possible to improve clinical outcomes and lower the total cost of care.

Author Affiliations: Devoted Health (NW, CC, PDC), Waltham, MA; Harvard Medical School (NW), Boston, MA; Baylor College of Medicine (CC), Houston, TX; Yale School of Medicine (PDC), New Haven, CT; Stanford Medicine (BK), Palo Alto, CA; USC Schaeffer Center for Health Policy & Economics (BK), Los Angeles, CA; Venrock (BK), Palo Alto, CA.

Source of Funding: None.

Author Disclosures: Drs Wagle, Campbell, and Di Capua are employed by Devoted Health and own equity in Devoted Health. Dr Kocher is a board member of Devoted Health.

Authorship Information: Concept and design (NW, CC, PDC, BK); drafting of the manuscript (NW, CC, PDC, BK); critical revision of the manuscript for important intellectual content (NW, CC, PDC, BK); obtaining funding (NW); administrative, technical, or logistic support (NW); and supervision (NW).

Send Correspondence to: Bob Kocher, MD, Venrock, 3340 Hillview Ave, Palo Alto, CA 94304. Email: bkocher@venrock.com.

REFERENCES

1. Applegate WB, Ouslander JG, Kuchel GA. Implementing “patient-centered care”: a revolutionary change in health care delivery. J Am Geriatr Soc. 2018;66(10):1863-1865. doi:10.1111/jgs.15536

2. Blaum C, Hoy L, Rich MW, et al. Patient Priorities Care research agenda: results of multi-stakeholder engagement. Patient-Centered Outcomes Research Institute. March 2018. Accessed May 5, 2023. https://bit.ly/45GrgZQ

3. Naik AD, Dindo LN, Van Liew JR, et al. Development of a clinically feasible process for identifying individual health priorities. J Am Geriatr Soc. 2018;66(10):1872-1879. doi:10.1111/jgs.15437

4. Cohen SB, Yu W. The concentration and persistence in the level of health expenditures over time: estimates for the U.S. population, 2008-2009. Agency for Healthcare Research and Quality statistical brief No. 354. January 2012. Accessed May 5, 2023. https://meps.ahrq.gov/data_files/publications/st354/stat354.pdf

5. Bodenheimer T, Berry-Millett R. Care management of patients with complex health needs. Robert Wood Johnson Foundation. December 2009. Accessed May 5, 2023. https://bit.ly/45lZh1u

6. Joo JY, Huber DL. Case management effectiveness on health care utilization outcomes: a systematic review of reviews. West J Nurs Res. 2019;41(1):111-133. doi:10.1177/0193945918762135

7. Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of case management for ‘at risk’ patients in primary care: a systematic review and meta-analysis. PLoS One. 2015;10(7):e0132340.
doi:10.1371/journal.pone.0132340

8. Ouayogodé MH, Mainor AJ, Meara E, Bynum JPW, Colla CH. Association between care management and outcomes among patients with complex needs in Medicare accountable care organizations. JAMA Netw Open. 2019;2(7):e196939. doi:10.1001/jamanetworkopen.2019.6939

9. Tinetti ME, Naik AD, Dindo L, et al. Association of patient priorities–aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: a nonrandomized clinical trial. JAMA Intern Med. 2019;179(12):1688-1697. doi:10.1001/jamainternmed.2019.4235