Development of a Clinically Feasible Process for Identifying Individual Health Priorities

Aanand D. Naik, MD; Lilian N. Dindo, PhD; Julia R. Van Liew, PhD; Natalie E. Hundt, PhD; Lauren Vo, MS; Kizzy Hernandez-Bigos, BA; Jessica Esterson, MPH; Mary Geda, BN, MSN, RN; Jonathan Rosen, MD; Caroline S. Blaum, MD, MS; Mary E. Tinetti, MD

Disclosures

J Am Geriatr Soc. 2018;66(10):1872-1879. 

In This Article

Abstract and Introduction

Abstract

Objectives: To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making.

Design: Prospective development and feasibility study.

Setting: Primary care practice in Connecticut.

Participants: Older adults with 3 or more conditions or taking 10 or more medications (N=64).

Intervention: The development team of patients, caregivers, and clinicians used a user-centered design framework—ideate → prototype → test →redesign—to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators.

Measurements: We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions).

Results: We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians.

Conclusion: Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Introduction

Most older adults who receive health care have multiple chronic conditions. Health care for these older adults is complex, with inherent tradeoffs between desired outcomes or healthcare options and between outcome goals and healthcare preferences.[1] When faced with tradeoffs, people vary in their health and healthcare priorities.[2–5] Priorities include health outcome goals—what they want from their health care and their healthcare preferences—what healthcare activities they are willing and able to perform, and the care they are willing or not willing to receive.[6] Identifying priorities provides a means of reducing the tradeoffs between outcome goals, between healthcare preferences, and between outcome goals and healthcare preferences. Individuals with multiple chronic conditions (multimorbidity) report that the increasing number and complexity of tasks and activities, such as medication and diet regimens, healthcare visits, and self-monitoring tasks, are burdensome.[7–10] What clinicians bemoan as nonadherence may result from burdensome recommendations that are inconsistent with patient priorities.[11] Understanding patients' priorities can improve adherence to care because clinicians may be more likely to recommend aspects of healthcare that align with these priorities.

Aligning healthcare recommendations to achieve specific health outcome goals within the context of what people are willing and able to do is particularly important for adults with multiple conditions. Guideline-based decision-making can be burdensome and is of uncertain benefit for this population.[12] When patient priorities drive healthcare decisions, patients and clinicians can more appropriately address the inherent tradeoffs arising from conflicting health outcome goals, guidelines, and the burdens of such care.[6] Elaborating clear and concise priorities that inform decision-making is a challenge, requiring a reliable and efficient process for ascertaining patients' goals and preferences based on what matters most for them with their multiple conditions.

Most prior work on eliciting goals and preferences involved persons with advanced illness or near the end of life.[13–15] Tools that older adults with multiple chronic conditions can use to prioritize universal health outcomes exist, but they have not been tested in clinical encounters.[3,16,17] Goal attainment scaling (GAS) has been tested in several populations, focusing on outcomes important to older adults (e.g., function, safety), but does not link goals to treatment preferences.[18–20]

Collaborative goal-setting is an evidence-based process of developing a collaboratively agreed upon healthcare plan (tests and treatments, education and support, self-management) arising from patient priorities.[21,22] The approach has 4 components.[23] First, the person identifies his or her core values—what matters most to him or her. Values are fundamental beliefs about one's self and life that remain relatively stable over time.[24] Values are rooted in our affective neurobiology,[25] with culture and context giving them personal meaning.[26] Health values offer a framework and motivation to craft outcome goals that direct healthcare decisions.[24,27,28] Second, based on their values, individuals construct specific, measurable, actionable, realistic, and time-bound (SMART) outcome goals.[29] Third, individuals communicate with their clinicians about their priorities. The fourth component involves aligning treatment options with outcome goals and healthcare preferences to arrive at a healthcare plan.[30] Collaborative goal-setting improves disease-specific outcomes (e.g., blood pressure, glucose, depression symptoms), quality-of-life measures, patient activation, and self-efficacy.[21–23,30–34] Although promising, prior collaborative goal-setting studies have not focused on older adults with multiple chronic conditions.[7,9,10,35]

We developed and refined an approach to identify individual priorities that builds primarily on collaborative goal-setting to elicit health outcome goals and healthcare preferences.[7,9,10,13–24,31–35] The ultimate purpose of this process is to align healthcare with health priorities. This article describes the development, refinement, and testing of a clinically feasible approach to identifying patients' health priorities and concomitant training for healthcare professionals who will facilitate this identification of priorities.

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