Frequently Asked Questions
Patient Priorities Care aligns healthcare decision-making and care by all clinicians with patients’ own health priorities. Patient Priorities Care involves not only the health outcome goals that patients want to achieve, but also their preferences for healthcare. This approach is about aligning what outcomes patients want from their healthcare with what they are willing and able to do to achieve these outcomes. The approach begins with a member of the healthcare team helping patients identify their health outcome goals and their care preferences and preparing them to interact with their clinicians around these goals and preferences. The goals and preferences are transmitted to the patient’s clinicians who use them in decision-making and communication with the patient and other clinicians.
In the Patient Priorities Care context, health priorities refer to both an individual’s health outcome goals and care preferences—both are needed to drive decision-making and care. Health outcome goals are the personal health and life outcomes that patients hope to achieve through their healthcare (such as function, longevity, social activities, or symptom relief). SMART (specific, measurable, actionable, reliable, and time bound) goals give specificity so they can be used in decision-making. Care preferences refer to all aspects of healthcare (tests, health visits, procedures, medications) that individuals are able and willing to do, or tolerate, to achieve their health outcome goals.
A national group of clinicians, patients, caregivers, health system leaders, researchers, and health policy experts developed this approach to align healthcare among clinicians with each patient’s own priorities.
Patient Priorities Care integrates decision-making and care across conditions and clinicians by tailoring care options to those most consistent with each patient’s outcome goals and care preferences, rather than treating each individual disease in isolation. Patient Priorities Care relies on a patient’s own priorities to shape and align care.
Patient Priorities Care is not a type of care, but rather an approach to decision-making for all clinicians to use in helping patients select the best treatment for them. It is appropriate across the health continuum, but is especially helpful for older adults managing multiple conditions who do not yet have advanced illness or are not near the end of life. It is possible that some people will receive palliative care earlier than they might otherwise under this approach, because it is consistent with their own outcome goals and care preferences.
Patient Priorities Care works well for all patients. However, it can be of particular benefit to older adults who are struggling to manage their multiple conditions, who see multiple clinicians, who may receive conflicting recommendations, and who may be overwhelmed by their current care regimen.
Any member of the patient’s care team who knows the patient, has good interview skills, and is trained can do it. This may be a nurse, a physician’s assistant, or a social worker, for example. Training and point of care materials are available for the facilitators and patients. Patient Priorities Care is also developing a case-based online curriculum to prepare members of the healthcare team to become effective health priorities facilitators.
Patient Priorities Care refocuses care from treating patients’ individual diseases in isolation to aligning care to achieve each patient’s specific health priorities. Clear health priorities understood by patients, their family members, and their multiple clinicians reduces burdensome or unwanted care. This approach improves communications between patients and clinicians and helps patients be active partners in their healthcare decisions. Patient Priorities Care recognizes that patients are experts in what matters most to them about their health and healthcare and clinicians are experts in knowing how best to achieve what matters most.
Patient Priorities Care allows for better care without undue increase in clinical workloads. Clinicians will better understand their patients’ priorities, allowing them to more easily design a care regimen that is attuned to those priorities, thus improving patients’ adherence. Care will also be better integrated, so that clinicians who are part of a patient’s care team will not be at odds with each other. This approach can improve interactions among clinicians by aligning communications and decisions around the same patient health priorities.
By aligning care with patients’ priorities, health systems could see reduced unwanted utilization as patients select care that aligns more closely with what they want for their own lives. Patient satisfaction metrics for these systems would also likely increase with Patient Priorities Care, as patients grow more confident that their clinicians are listening to them and truly care about their priorities.
Patient Priorities Care is currently being piloted at ProHealth Physicians, a primary care network in Connecticut, and its partner cardiology practice. The pilot is building evidence about the approach and identifying how to best incorporate it into real-world workflows.
For Patients and Caregivers
Many older adults have multiple chronic conditions and see multiple clinicians. As a result, healthcare can get overwhelming and fragmented. Recommendations by different clinicians may conflict because what is good for one disease may be bad for another disease. People with multiple diseases and conditions vary in what matters most to them about their health and their healthcare. When a patient knows what his or her health and life outcome goals are, it helps the patient’s clinicians provide the least burdensome care with the best health outcomes. It ensures that all of a patient’s clinicians are on the same page when it comes to caring for his or her multiple conditions.
The more clinicians know about patients and their specific health outcome goals and care preferences, the better care they will be able to provide now and in the future. Thinking about and identifying their health outcome goals and care preferences also helps patients be better informed about their healthcare and their treatment options.
Many patients are not used to being asked these types of questions or receiving this type of care. People vary in how ready or comfortable they are. Some get to SMART (specific, measurable, actionable, reliable, and time bound) goals and specific care preferences quickly, while others need time. In all cases, a member of the healthcare team will assist the patient in the way that works best for that particular patient. They may start with asking about activities the patient finds pleasurable as a way to help them identify your values and goals. They may ask the patient to describe a good day and a bad day (as well as a desired good day). They may start by asking the patient what about his or her current healthcare regimen is helping and doable, and what isn’t helping or is too burdensome.
Patient Priorities Care does not ask clinicians to ignore disease guidelines, but rather to acknowledge that their usefulness is uncertain in older adults with multiple conditions who are often excluded from clinical trials. The evidence from these studies may not apply to these patients. Also, older adults may accrue less benefit and more harm than suggested in disease guidelines because of competing coexisting conditions and treatments. Patient Priorities Care asks clinicians to interpret disease guidelines through the lens of whether the recommendations are consistent with each patient’s health outcome goals and care preferences.
Most clinicians do consider patient preferences and goals. Patient Priorities Care improves clinicians’ ability to do this effectively by making sure that patient’s health outcome goals and care preferences, are SMART (specific, measurable, actionable, reliable, and time bound) so that they can be used in making the best decisions in the face of difficult tradeoffs. Patients’ own health outcome goals and care preferences anchor conversations around the many tradeoffs involved in decision-making with patients with multiple conditions. Decision-making for clinicians shifts from, “You need (test or treatment) because of your (disease),” to “I’m recommending (starting, continuing, or stopping treatment) because it will help you achieve (patient’s goal) and is consistent with (patient’s care preference).”
This approach also may improve communication and information transmission between clinicians by aligning communications and decisions around the same patient health priorities. Because SMART goals and care preferences are measurable, they can be the yard stick to measure how care is going.
Goals and care preferences should and do change as health or life circumstances change. What is less likely to change are the underlying values from which individuals’ goals arise. Once individuals understand the process of identifying their values-based SMART goals and care preferences, these can be updated as needed.
Health goals that are aspirational are okay—as long as they are not unrealistic. It can take time for patients to adjust to SMART goals, and it is okay to use evolving goals to focus and direct discussion and decision-making. If a goal is not achievable, there are almost always alternative SMART goals that can be formulated that also serve a patient’s underlying core values.
Knowing the patient’s health priorities allows clinicians to communicate to families that what they want for their loved one may be different from what the patient wants—but that it is important to focus on what the patient wants. If possible, the key caregivers should be present when a clinician elicits the patient’s health outcome goals and care preferences. The clinician can then reinforce the idea that it’s the patient’s, not the family member’s, goals and preferences that determine appropriate care. If the goals and preferences are elicited and communicated when the patient is stable and not facing crises, it is easier for the clinician to interact with family members during a time of crisis.
Ideally the goals and preferences are placed in a readily accessible place in the electronic health record (EHR) to be used and updated by all clinicians. Patient Priorities Care has created and tested simple, one-page templates to convey the key priorities-related information. When clinicians use different EHRs, the goals and preferences should be transmitted through the secure systems used to convey other health information. Each patient should also own a copy that they take with them to every visit. To ensure that all decisions are aligned with a patient’s priorities, communications between clinicians should be based on each patient’s specific outcome goals and care preferences.
Patient Priorities Care supports the clinical decision-making that is a part of every clinical encounter. Therefore, it is billed just like any other visit. Clinicians can bill by time for extended visits when they are first initiating this approach to care. The Centers for Medicare and Medicaid Services billing codes for advance care planning, goals of care discussions, and chronic disease management can also support the time spent eliciting and updating patients’ health priorities and integrating care around these priorities.
An online curriculum that prepares members of the healthcare team to help patients identify their SMART goals and care preferences and translate them into decision-making is under development in concert with the American College of Physicians. In addition, we are working out the key steps to incorporating Patient Priorities Care into the clinical workflow. These steps will soon be available on this website. For more information, you can contact us here.
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