Implementation Toolkit Test

Categories: Getting Started, Training, Point of Care Tools and Decisional Support, Billing and Business Case

 Before you start implementing the Patient Priorities Care approach into your health system or practice think about:

Is leadership willing to consider patient priorities care?

• Leadership feels Patient Priorities Care fits the mission of the organization (e.g. could improve patient and clinician satisfaction, improve market share and improve unwanted utilization). See Age Friendly Health System connection to What Matters Most as a tool to help promote buy-in.

• Leadership is willing to endorse or sponsor the implementation of this approach

• Willing to commit modest resources* for preparing clinicians and staff to provide Patient Priorities Care and integrating it into the workflow (*time and money to prepare the clinicians and staff, and set up implementation of Patient Priorities Care)

If leadership interested, then consider whether your setting is appropriate (recognizing the Patient Priorities Care approach will be adapted to your setting).

• Time can be set aside for training in both priorities identification and aligning care as appropriate

• Clinicians and other team members committed to initial and ongoing training in patient priorities aligned care and decision making, including case-based huddles.

• Clinicians committed to implementing patient priorities aligned decision making and care by aligning care with each patient’s health priorities:
  • Start encounters by reviewing patient’s health priorities.
  • Consider if the patient’s current and potential care is consistent with patient’s health outcome goals & care preferences.
  • Use the patient’s One Thing to select care likely to achieve patient’s health goals.
  • Use PPC strategies in clinical decision- making and communication with patients and other health professionals.
  • Document patient priorities informed decisions.

• Clinician who is willing to champion and lead the effort by being trained in PPC and facilitating training and support for the team.

• Support for preparation time for clinicans and staff exist.

• The IT component of the PPC approach is feasible (i.e. you can document, communicate and update patient priorities in a place accessible to all clinicians and patients)

• There is support for facilitating the use of appropriate billing codes to support PPC (see Billing for more information).

• Care for older adults with multiple chronic conditions (e.g. at least 10% patient population). PPC is particularly useful for complex older adults for whom disease-based guidelines are not applicable. Read More Here (link to Are Disease-Specific, Evidence-Based Guidelines Applicable?)

Preferred/Optional:

• Working relationships between primary and specialty clinicians

• Willing to provide the time and effort to collect modest amount of data to evaluate processes and outcomes of Patient Priorities Care

• Health care team members who can conduct health priorities identification (i.e. help patients identify their health priorities – This can be done in person, by phone, or virtual (telemedicine) visit)*.

• Capability exists for tracking healthcare utilization data and costs in order to evaluate the effectiveness/value of this approach
• Administrative staff who can become familiar with PPC, support the team and help incorporate PPC into the workflow

*Any member of the healthcare team – medical assistant, nurse, APRN, case coordinator, physician assistant, SW, MD (preferably with motivational interviewing skills) can identify patients’ health priorities. For patients and caregiver who are able and interested, self-directed website for patients (and/or caregivers) to identify health priorities is available at www.MyHealthPriorities.org

Key Resources/Tools: Age Friendly Health System connection to What Matters Most; Are Disease-Specific, Evidence-Based Guidelines Applicable?

Additional resources: See Billing and Business Case for more resources for getting buy-in