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Learning Collaborative meeting summaries: Session #1 on June 11, 2024 – Kickoff meeting, defining key elements of PCCP and what works in a real-world setting Session #2 on August 13, 2024 – Patient Priorities Care, Care Management Plus, GUIDE models; baseline environmental scan results Session #3 on September 30, 2024…

CollaboRATE measure of level of shared decision-making in a clinical encounter: https://www.glynelwyn.com/collaborate.html Measure Yourself Medical Outcome Profile: https://www.physio-pedia.com/MYMOP_-_Measure_Yourself_Medical_Outcome_Profile

The eCare Plan and MyCarePlanner applications facilitate shared care planning for people with MCC. They can aggregate data from multiple EHRs and can collect patient-reported social needs, caregiver needs, and function. The FHIR Implementation Guide is publicly available: https://hl7.org/fhir/us/mcc/STU1/index.html eCare Plan Index: https://www.ahrq.gov/ecareplan/index.html MCC eCare Plan Implementation Guide: https://build.fhir.org/ig/HL7/fhir-us-mcc/branches/master/index.html The…

Optimizing Health and Function as We Age: Roundtable Report. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0059. https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf Report to Congress – Aging in the United States: A Strategic Framework for a National Plan on Aging https://acl.gov/sites/default/files/ICC-Aging/StrategicFramework-NationalPlanOnAging-2024.pdf AHRQ Strategic Plan for Health System Transformation…

Age-Friendly Health Systems: Initiative to encourage age-friendly evidence-based practices to align with what Matters to older adults and their family caregivers, using the 4Ms framework: What Matters, Medication, Mentation, and Mobility. https://www.ihi.org/networks/initiatives/age-friendly-health-systems https://institute.agefriendly.com/ Agency for Community Living (ACL) Community Care Hubs: Community care hubs aim to help community-based organizations and…

Abbasi AB, Layden J, Gordon W, et al. A Unified Approach to Health Data Exchange: A Report From the US DHHS. JAMA. 2025;333(12):1074–1079. doi:10.1001/jama.2025.0068 American Geriatrics Society Expert Panel on Person-Centered Care. Person-Centered Care: A Definition and Essential Elements. J Am Geriatr Soc. 2016;64(1):15-18. doi:10.1111/jgs.13866 Baker A, Cronin K, Conway…

The Multiple Chronic Conditions Resource Center (MCCRC) is one of several resources held under the umbrella of HealthCom Media. The MCCRC provides clinical practice and health policy updates for healthcare professionals, patients, families and policymakers. It is a one-stop source for all current evidence based guidelines and resources. Sign up…

The Agency for Healthcare Research and Quality (AHRQ) has long-been advocates for promoting person-centered care. AHRQ has recently established a Learning Community (LC) to discuss models of person-centered care planning (PCCP) and real-world implementation with front-line providers. The LC will evaluate barriers and feasible solutions to meet the complex care…

The Hartford Foundation, Institute for Healthcare Improvement, American Hospital Association, and the Catholic Health Association among other agencies are promoting a healthcare system that we want for ourselves and others. Recognizing the need for improved care for the nation’s largest patient population – those living with 2 or more chronic…

There is a branding problem with palliative care in that it is associated with end of life, hospice or serious illness. Palliative care is also symptom management – skilled clinical decision making that improves patient quality of life – allowing for greater physical functioning and engagement in meaningful activities. Palliative…