News and Updates for Healthcare Professionals

View the recent Webinar from the Primary Care Collaborative and American College of Clinical Pharmacy’s on Managing Chronic Conditions with Team-Based, Whole-Person Primary Care.

On May 20, the Primary Care Collaborative (PCC) and American College of Clinical Pharmacy (ACCP) held a webinar exploring the powerful role coordinated, team-based approaches to whole-person primary care can play in battling against chronic illnesses, such as Type II diabetes and cardiovascular disease.
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Person-Centered Care in Multiple Chronic Conditions

Person-centered care as defined by the Agency for Healthcare Research and Quality (AHRQ) means that individuals’ values and preferences are elicited and once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires.

With support from the Agency for Healthcare Research and Quality, a learning collaborative comprised of frontline implementers, innovators, and researchers with expertise in person-centered care planning was formed to discuss models and implementation of PCCP. The learning collaborative participated in six learning sessions from June 2024 to January 2025. Below is a compendium of PCCP models, resources, and materials that were shared by community members during learning sessions.

Medication Safety

In 2023, the CDC reported that the most common types of adverse drug events are associated with allergic reactions, side effects, over-medication, medication errors, and drug–drug interactions. Healthcare advances in new drug development, older medications with newer indications for use, an aging population, and the expansion of prescription drug coverage may lead to an increase in these events. When nurses understand what determines evidence, how to implement guidelines as standard of care, and what establishes best practices to optimize medication safety, they can help prevent medication errors.

Patients have long associated trust and respect with nursing. However, recent incidents of nurses delivering inappropriate medications (wrong drug, wrong dose) have led to catastrophic consequences. Most notoriously, former nurse RaDonda Vaught was stripped of her nursing license and charged with reckless homicide and abuse of an impaired adult.

Anticholinergics, widely used in clinical practice for an extensive range of diseases, exert effects on circulation, respiration, alertness, and vision by blocking the action of acetylcholine (a neurotransmitter) within the choli­nergic sys­tem.

Providers prescribe benzodiazepines (BZDs)—also known as anxiolytics, hypnotics, muscle relaxants, anticonvulsants, and amnestic medications—to manage several symptoms and conditions, including anxiety, insomnia, alcohol withdrawal, sedation, muscle spasms, agitation, and seizures.

To ensure safety and effective care, nurses must maintain their knowledge and understanding of opioid pharmacologic properties and best practices when caring for patients with acute and chronic non-cancer pain.

Federal Initiatives for Persons with Multiple Chronic Conditions

Agency for Healthcare Research and Quality

Three Notice of Funding Opportunity for AHRQ’s Health Extension Collaboratives, National Coordinating Center, and National Evaluating Center are now all available. This includes fifteen grants for state-based Healthcare Extension Cooperatives to accelerate the dissemination and implementation of patient-centered outcomes research evidence into healthcare delivery. The National Coordinating Center will provide technical assistance, learning networks, communications, and dissemination guidance to the healthcare extension cooperatives. The National Evaluation Center will assess program implementation and impact. Information about a technical assistance webinar for this funding announcement is forthcoming. Questions may be submitted to AHRQ_HES@ahrq.hhs.gov.

More: Person-Centered Care Planning for People Living with or at Risk for Multiple Chronic Conditions

News and Updates for the Patient and Family

How Patients with Multiple Chronic Conditions Can Benefit from Home Healthcare Tools and Remote Patient Monitoring

By: Steven John Cumper, B.App.Sc. (Osteo.), M.Ost. Patients with multiple chronic conditions (MCC), or two or more conditions have complex care needs. These needs require ongoing home monitoring to prevent an escalation in their disease – such as an exacerbation, admission into hospital, debility and reduced physical functioning. Healthcare professionals…
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Dr Kim Kuebler Implementing Palliative Care in Multiple Chronic Conditions in the U.S.

Dr Arlene Bierman MD, MS, Director of Center for Evidence and Practice Improvement: Agency for Healthcare Research and Quality

Dr Joanne Lynn MD, MA, MS, Director Center for Elder Care and Advanced Illness, Altarum Institute

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Latest Posts from Our Blog

2024-2025 Agency for Healthcare Research and Quality’s Learning Collaborative Person-Centered Care Planning for Persons with or at Risk for Multiple Chronic Conditions.

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…
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Person-Centered Care Measures

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
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Person-Centered Care Health IT Tools

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…
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Person-Centered Care Policies, Reports and Communiqués

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…
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Person Centered Care Planning for Persons with Multiple Chronic Conditions

Arlene Bierman MD, MS, Agency for Healthcare Research and Quality, Brittany Watson MD, MPH, Wake Forest University School of Medicine, Jane Pederson MD, MS, Stratis Health – discuss the recent JAMA Online publication Person-Centered Care Planning for People Living with or at Risk for Multiple Chronic Conditions. Discussion includes federal…
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Medication Safety: Knowledge is Power

In this webinar, Dr. Kim Kuebler, DNP, APRN, ANP-BC, FAAN goes over medication safety, which includes reviewing how long it takes a drug to come to market, describing the difference between an FDA approved medication and compounded medications, and much much more.
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