Person-Centered Care Archives - Multiple Chronic Conditions https://multiplechronicconditions.org/category/person-centered-care/ FREE resources to educate, update and promote best practices that ensure optimal patient-centered outcomes. Fri, 22 Aug 2025 14:40:39 +0000 en-US hourly 1 https://wordpress.org/?v=6.9.4 https://multiplechronicconditions.org/wp-content/uploads/2024/03/mcc-icon-150x150.png Person-Centered Care Archives - Multiple Chronic Conditions https://multiplechronicconditions.org/category/person-centered-care/ 32 32 Environmental Scan for Person-Centered Care Planning in MCC https://multiplechronicconditions.org/person-centered-care/environmental-scan-for-person-centered-care-planning-in-mcc/ Fri, 22 Aug 2025 14:40:39 +0000 https://multiplechronicconditions.org/?p=4075 Baseline Scan: Person-Centered Care Planning for Persons with Multiple Chronic Conditions: Current Approaches and Models (PDF, 2 MB); Appendices (PDF, 430 KB): This baseline scan provides a summary of the approaches and models of person-centered care planning (PCCP) for people living with or at risk of developing multiple chronic conditions (MCC) with the goal of...

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Rapid Scan:

Rapid Scan:

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]]> 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. https://multiplechronicconditions.org/person-centered-care/2024-2025-agency-for-healthcare-research-and-qualitys-learning-collaborative-person-centered-care-planning-for-persons-with-or-at-risk-for-multiple-chronic-conditions/ Mon, 23 Jun 2025 15:33:51 +0000 https://multiplechronicconditions.org/?p=3999 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 – Chronic Care Model in...

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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 – Chronic Care Model in Janus Healthcare, 4Ms in Northwest Health, and social determinants of health in low-resource settings

Sessions #4/5 on November 4, 2024 – Implementing a PCCP initiative using Kotter’s model of change, and Contextualizing Care

Session #6 on January 21, 2025 – Rapid scan results, summarizing our learnings, next steps

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]]> Person-Centered Care Measures https://multiplechronicconditions.org/person-centered-care/person-centered-care-measures/ Mon, 23 Jun 2025 14:42:57 +0000 https://multiplechronicconditions.org/?p=3991 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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]]> 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 https://multiplechronicconditions.org/person-centered-care/person-centered-care-health-it-tools/ Mon, 23 Jun 2025 14:41:30 +0000 https://multiplechronicconditions.org/?p=3989 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 Community Care Hub IT Playbook...

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]]> 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 Community Care Hub IT Playbook is a self-guided tool on technical and information technology needs to foster interoperability: https://acl.gov/sites/default/files/programs/2024-07/Community%20Care%20Hub%20IT%20Playbook.pdf

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]]> Person-Centered Care Policies, Reports and Communiqués https://multiplechronicconditions.org/person-centered-care/person-centered-care-policies-reports-and-communiques/ Mon, 23 Jun 2025 14:40:01 +0000 https://multiplechronicconditions.org/?p=3985 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 To Optimize Health, Functional Status,...

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]]> 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 To Optimize Health, Functional Status, and Well-Being Among Older Adults https://www.ahrq.gov/priority-populations/publications/aging-well.html

Priority Populations index: https://www.ahrq.gov/priority-populations/about/index.html

HHS Call to Action Addressing Health-Related Social Needs in Communities Across the Nation https://aspe.hhs.gov/sites/default/files/documents/3e2f6140d0087435cc6832bf8cf32618/hhs-call-to-action-health-related-social-needs.pdf

Senator King request to examine the Impact of Ageism in Healthcare
Letter: https://www.kaine.senate.gov/imo/media/doc/ahrq_letter.pdf
Press release: https://www.king.senate.gov/newsroom/press-releases/king-calls-for-study-on-hidden-costs-of-ageism-on-health-care

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]]> Person-Centered Care Programs and Training https://multiplechronicconditions.org/person-centered-care/person-centered-care-programs-and-training/ Mon, 23 Jun 2025 14:35:16 +0000 https://multiplechronicconditions.org/?p=3980 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 health care payers increase the...

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    1. 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/
    2. Agency for Community Living (ACL) Community Care Hubs: Community care hubs aim to help community-based organizations and health care payers increase the community’s capacity to address health-related social needs to support aging community members. See also Community Care Hub IT Playbook in Health IT Tools below.
      https://acl.gov/programs/strengthening-aging-and-disability-networks/improving-business-practices
    3. American College of Physicians training modules: The ACP offers training modules on many topics relevant to clinicians (continuing education and maintenance of certification available). The linked tool from Patient Priorities Care can help patients identify their health priorities.
      https://www.acponline.org/clinical-information/clinical-resources-products/decision-making-for-patients-with-multiple-chronic-conditions-patient-priorities-care
    4. Collaborative Care Model: This model supports integration of physical and behavioral health care.
      Brief related to CCM – https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf
      Delivery through Janus Health: https://janushcp.com/
    5. Community Aging in Place Advancing Better Living for Elders (CAPABLE): The program supports aging community members to remain in their homes through occupational therapy, nursing, home safety, and handy worker services.
      https://capablenationalcenter.org/
      Training: (https://capablenationalcenter.org/training-overview/)
    6. Contextualizing Care: Research program that uses direct observations to characterize the pattern of errors in physicians’ ability to provide patient-centered, or contextualized, care.
      https://www.contextualizingcare.org/
    7. Neighborhood Nursing: Brings care directly to where people live to support and strengthen communities.
      https://nursing.jhu.edu/faculty-research/research/areas-of-expertise/community-global-health/center-community-innovation-scholarship/neighborhood-nursing/
      Stories: https://www.npr.org/sections/shots-health-news/2024/06/11/nx-s1-4997717/nurses-primary-care-community-baltimore-costa-rica
      Stories: https://www.pbs.org/newshour/show/neighborhood-nursing-brings-healthcare-to-peoples-doorsteps-in-vulnerable-communities
    8. Patient Priorities Care: Patient Priorities Care delivery uses the 4 Ms framework of Age-Friendly Health Systems and includes multiple resources to enable care settings to use the materials.

    • Tools for patients/caregivers (electronic manual, tips), clinicians (electronic manuals, materials, publications, and key definitions) https://patientprioritiescare.org/
    Decisional guidance (tips & scripts) tool http://decisionguide.patientprioritiescare.org/
    Self-directed health priorities identification https://myhealthpriorities.org/

     

    https://www.tragerinstitute.org/

     

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    ]]>         Person-Centered Care Publications https://multiplechronicconditions.org/person-centered-care/person-centered-care-publications/ Mon, 23 Jun 2025 14:16:39 +0000 https://multiplechronicconditions.org/?p=3978 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 PH, DeSalvo KB, Rajkumar R,...

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    ]]>     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 PH, DeSalvo KB, Rajkumar R, Press MJ. Making the Comprehensive Shared Care Plan a Reality. NEJM Catalyst. May 18, 2016. https://catalyst.nejm.org/doi/full/10.1056/CAT.16.0838

    Bierman AS, Wang J, O’Malley PG, Moss DK. Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda. Health Serv Res. 2021;56 Suppl 1(Suppl 1):973-979. doi:10.1111/1475-6773.13863

    Blaum CS. Resnick HE. Lawton D. Bowman A. A Core Measure Set For Age-Friendly Health Care Delivery“, Health Affairs Forefront, September 13, 2024. https://www.healthaffairs.org/content/forefront/core-measure-set-age-friendly-health-care-delivery

    Chappel A, Cronin K, Kulinski K, Whitman A, DeLew N, Hacker K, Bierman AS, Meklir SW, Monarez SC, Johnson KA, Whelan EM, Jacobs D, Sommers BD. Improving Health And Well-Being Through Community Care Hubs. Health Affairs Forefront. 2022 Nov 29. DOI: 10.1377/forefront.20221123.577877

    Dolin G, Saitwal H, Bertodatti K, Mueller S, Bierman AS, Suls J, Brandt K, Camara DS, Leppry S, Jones E, Gallego E, Carlson D, Norton J, Establishing data elements and exchange standards to support long COVID healthcare and research, JAMIA Open, Volume 7, Issue 3, October 2024, ooae095, https://doi.org/10.1093/jamiaopen/ooae095

    Dorr DA, Wilcox A, Jones S, Burns L, Donnelly SM, Brunker CP. Care management dosage. J Gen Intern Med. 2007;22(6):736-741. doi:10.1007/s11606-007-0138-z

    Fowler E. Brooks-LaSure C, Rawal P. Innovation At CMS: Advancing A Person-Centered Health System. Health Affairs, January 15, 2025. DOI: 10.1377/forefront.20250113.153827

    Fulmer T, Patel P, Levy N, Mate K, Berman A, Pelton L, Beard J, Kalache A, Auerbach J. Moving Toward a Global Age-Friendly Ecosystem. J Am Geriatr Soc. 2020 Sep;68(9):1936-1940. doi: 10.1111/jgs.16675. Epub 2020 Jul 23. PMID: 32700767.

    Jennings LA, Tan Z, Wenger NS, et al. Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program. J Am Geriatr Soc. 2016;64(8):1724-1730. doi:10.1111/jgs.14251

    Kuebler K, Monroe T, Ricciardi R, Westlake C, Sorenson M, Pederson J, Neft M, Mitchell SA, Daniel K, De Santo-Madeya S, Renda S, Henneman E, Bruera E. Integration of palliative care in the management of multiple chronic conditions: An expert consensus paper with policy implications. Nursing Outlook 72(2024)102273. https://doi.org/10.1016/j.outlook.2024.102273

    Gottlieb LM, Hessler D, Wing H, Gonzalez-Rocha A, Cartier Y, Fichtenberg C. Revising the Logic Model Behind Health Care’s Social Care Investments. Milbank Q. 2024 Jun;102(2):325-335. doi: 10.1111/1468-0009.12690. Epub 2024 Jan 25. PMID: 38273221; PMCID: PMC11176407.

    Gottlieb LM, Lindau ST, Peek ME. Why Add “Abolition” to the National Academies of Sciences, Engineering, and Medicine’s Social Care Framework? AMA J Ethics. 2022 Mar 1;24(3):E170-180. PMID: 35325517; PMCID: PMC9591153. doi: 10.1001/amajethics.2022.170.

    Kelley AT, Weiner SJ, Francis J. Directly Observed Care: Crossing the Chasm of Quality Measurement. J Gen Intern Med. 2023;38(1):203-207. doi:10.1007/s11606-022-07781-1

    Marulappa, N, Anderson NN, Bethell J, Bourbonnais A, Kelly F, McMurray J, Rogers HL, Vedel I, Gagliardi AR. How to implement person-centred care and support for dementia in outpatient and home/community settings: Scoping review. BMC Health Serv Res. 2022;22(541). https://doi.org/10.1186/s12913-022-07875-w

    National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington (DC): National Academies Press (US); 2019 Sep 25. PMID: 31940159.

    Reuben DB, Tinetti ME. Goal-oriented patient care–an alternative health outcomes paradigm. N Engl J Med. 2012 Mar 1;366(9):777-9. PMID: 22375966. doi: 10.1056/NEJMp1113631.

    Reuben DB, Jennings LA. Putting Goal-Oriented Patient Care Into Practice. J Am Geriatr Soc. 2019 Jul;67(7):1342-1344. Epub 2019 Mar 18. PMID: 30882888. doi: 10.1111/jgs.15885

    Sadak T, Wright J, Borson S. Managing Your Loved One’s Health: Development of a New Care Management Measure for Dementia Family Caregivers. J Appl Gerontol. 2018;37(5):620-643. doi:10.1177/0733464816657472

    Tinetti ME, Hladek MD, Ejem D. One Size Fits All-An Underappreciated Health Inequity. JAMA Intern Med. 2024 Jan 1;184(1):7-8. PMID: 37983054. doi: 10.1001/jamainternmed.2023.6035.

    Schwartz A, Weiner SJ, Harris IB, Binns-Calvey A. An educational intervention for contextualizing patient care and medical students’ abilities to probe for contextual issues in simulated patients. JAMA. 2010;304(11):1191-1197. doi:10.1001/jama.2010.1297

    Watson BN, Estenson L, Eden AR, Gerstein MT, Carney MT, Dotson VM, Milnes T, Bierman. Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions. JAMA Netw Open. 2024;7(10):e2439851. doi:10.1001/jamanetworkopen.2024.39851

    Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022;105(3):594-598. doi:10.1016/j.pec.2021.06.016

    Weiner SJ, Kelly B, Ashley N, et al. Content coding for contextualization of care: evaluating physician performance at patient-centered decision making. Med Decis Making. 2014;34(1):97-106. doi:10.1177/0272989X13493146

    Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002

    Weiner SJ, Schwartz A, Weaver F, Galanter W, Olender S, Kochendorfer K, Binns-Calvey A, Saini R, Iqbal S, Diaz M, Michelfelder A, Varkey A. Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial. JAMA Netw Open. 2022;5(10):e2238231. doi:10.1001/jamanetworkopen.2022.38231

    Weiner S, Schwartz A, Altman L, et al. Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open. 2020;3(7):e209644. Published 2020 Jul 1. doi:10.1001/jamanetworkopen.2020.9644

    Weiner SJ, Schwartz A, Sharma G, et al. Patient-collected audio for performance assessment of the clinical encounter. Jt Comm J Qual Patient Saf. 2015;41(6):273-278. doi:10.1016/s1553-7250(15)41037-2

    Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158(8):573-579. doi:10.7326/0003-4819-158-8-201304160-00001

    Winslow VA, Lindau ST, Huang ES, et al. Caring for dementia caregivers: How well does social risk screening reflect unmet needs? J Am Geriatr Soc. 2024; 1-11. doi:10.1111/jgs.19200

    Selected articles from Medical Care Special Issue on Measuring What Matters Most, December 2024
    Measuring What Matters Most: Considering the Well-Being of the Whole Person in Health Care Medical Care 62(12):p i, December 2024. | DOI: 10.1097/MLR.0000000000002103

    Bokhour BG, Vogt D, Kligler B. Measuring What Matters Most: Considering the Well-Being of the Whole Person in Health Care. Medical Care 62(12):p S1-S3, December 2024. | DOI: 10.1097/MLR.0000000000002088

    Etingen B, Cohen-Bearak A, Adjognon OL, Vogt D, Hogan TP, Gaj L, Orner MB, Barker AM, Bokhour BG. Measuring Patient Well-Being During Whole-Person Clinical Care: Lessons From the Veterans Health Administration Well-Beings Signs Implementation Pilot. Medical Care 62(12):p S57-S64, December 2024. | DOI: 10.1097/MLR.0000000000002054

    Herman PM, Rodriguez A, Edelen MO, DiGuiseppi G, Zeng C, Coulter ID, Hays RD. A Perspective on the Measurement of Whole Person Health. Medical Care 62(12):p S24-S26, December 2024. | DOI: 10.1097/MLR.0000000000002047

    Parr NJ, Young S, Baltich Nelson B. Assessing Whole-Person Outcomes During Routine Clinical Care: A Rapid Scoping Review. Medical Care 62(12):p S34-S42, December 2024. | DOI: 10.1097/MLR.0000000000002046

    Vogt D, Kligler B, Darchuk K, Elbogen E, List JM, McMullen T, Murphy JL, Bokhour BG. Measuring the Well-Being of the Whole Person in Clinical Care, Health Research, and Population Health Evaluation: Findings and Recommendations From the XVIII Veterans Health Administration State of the Art Meeting. Medical Care 62(12):p S4-S12, December 2024. | DOI: 10.1097/MLR.0000000000002084

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