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


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

In This Article


Development of a Values-based Patient Priorities Identification Process

A user-centered design framework (ideate → prototype → test →redesign) was adapted to develop the patient priorities identification process.[36] The investigators developed the core concepts (ideate) through a synthesis of prior literature and input from advisory panels consisting of 6 patients or caregivers; 7 primary care providers (PCPs); 8 specialty clinicians; 3 payers; 5 health system leaders; 5 patient, caregiver, and clinician organization representatives; 3 health informatics technology experts; and 2 redesign experts. From January 2014 to June 2015, advisory panels convened 39 times to identify modifiable contributors to fragmented, burdensome care and determine core elements for building a feasible, sustainable approach to improving care by addressing these factors.[6,37] This process, described previously,[6] culminated in development of a logic model for patient priority-aligned care, which begins with patients identifying and communicating their health priorities. These priorities guide interactions between patients, caregivers, and clinicians as they select care options.[6] The core steps for the patient priorities identification process are described in Table 1.

Patient Priorities Identification Process. PCPs invited their patients to collaborate with a facilitator (described below) to identify their health priorities. Multiple practice change strategies, described elsewhere,[38] were used to ensure buy-in and participation of PCPs. Each step in the patient priorities identification process has a defined purpose and content adapted from our prior studies.[23,24,39,40] These steps occurred in a clinical setting, the patient's home, or over the telephone over 1 to 2 sessions, depending on each patient's preferences, circumstances, and readiness. The patient priorities identification process moved through values clarification to values-informed elaboration of goals and preferences and a conversation about tradeoffs. We developed patient and facilitator manuals to guide participants through the process. The facilitator manual mirrored the patient manual with the addition of instructions on how to guide patients through the steps and tips for addressing commonly encountered challenges. Patient advocates and experts in health literacy suggested edits to the patient manual.

Refinement of the Patient Priorities Identification Process. Modifications to the identification process and accompanying manuals were based on input from facilitators' initial experiences with patients and every-other-week teleconferences with the development team from October 2016 to July 2017. The most important refinement was addition of the fourth step, which focused on encouraging patients to interact with their PCPs regarding their goals and preferences.

The primary outcome of this process is the elaboration of a set of health priorities, consisting of health outcome goals and healthcare preferences, which are transmitted to the healthcare team by scanning a completed template into the electronic health record. The workflow for transmitting health priorities is described elsewhere.[38] Patients are encouraged to share their priorities with their clinicians and prompt their clinicians to consider how currently recommended care aligns with the patient's health priorities. Table 1 provides a comprehensive description of the 4–step patient health priorities identification process. (Supplemental Figure S1 provides an overview.)

Supplemental Figure S1 Legend.

Figure provides a comprehensive description of the four-step patient health priorities identification process between the facilitator and patient. Patients are invited to participate in the process by their clinician. The four-step process results in the development of a Patient Priorities document in the electronic health record. Clinicians use the document to guide future discussions with the patient to conduct Patient Priorities-aligned Care.

Training of Priority Facilitators

Facilitators are health professionals who help patients identify their health priorities. Facilitators who participated in the current feasibility study included an advanced practice registered nurse and a member of the healthcare team with case management experience, both employed by the large primary care practice. Facilitators prepared for training by reviewing the facilitator manual. Training began with a face-to-face session in which facilitators practiced the process with a member of the development team and then with a standardized patient. Facilitators then tested the process with 10 patients, during which time they observed each other and gave feedback.

Feasibility Testing

We conducted an open, single-arm feasibility assessment of the revised patient priorities identification process from October 1, 2016, to July 31, 2017. This feasibility pilot involved older patients with multiple morbid conditions and the 2 facilitators that the development team trained. The institutional review board of Yale School of Medicine approved this study.

Patient Participants. Patients aged 65 and older were drawn from an existing Medicare population of a large primary care practice. Patient panels were screened for eligibility based on the presence of of the following inclusion criteria: English-speaking and 3 or more chronic conditions, taking 10 or more medications, or seen by more than 2 specialists. Exclusion criteria included known diagnosis of advanced dementia, chronic dialysis, residing in a nursing home, and meeting hospice criteria. Persons with mild cognitive impairment were included per judgement of their PCP. Between October 1, 2017, and July 31, 2017, 119 persons were offered patient priorities identification. Of these, 69 were contacted to complete a baseline interview for the patient priorities care project. These patients were eligible for inclusion in this study. The remaining 50 individuals had returned to their PCP before we were able to contact them, precluding our ability to obtain their baseline interview.

Quantitative Evaluation of Feasibility. Descriptive data included sociodemographic characteristics and Treatment Burden Questionnaire[9] and Patient-Reported Outcomes Measurement Information System Physical and Mental Health subscale scores.[42] Assessments of feasibility include the number who agreed to undergo and complete the patient priorities identification process and the number and duration of visits required to complete identification.

Qualitative Interviews with Facilitator Participants. Facilitators were interviewed using open-ended questions to elicit perceptions of the patient priorities identification process. Facilitators were asked: How would you describe your experiences with facilitating patients' priorities? and How does it compare with your typical encounters with patients? Facilitators were also asked to comment about which parts worked well, which were challenging, which they would change, and which they perceived that patients valued most.

Analysis. We calculated frequencies, proportions, and distributions for all quantitative variables using descriptive statistics. Qualitative data were analyzed using the constant comparative method of qualitative analysis.[41,43] Interview transcripts were reviewed line by line to identify and sort segments of data with similar concepts into distinct themes. Following coding by a lead analyst (JVL), additional investigators (AN, LD, MT) reviewed, negotiated, and reached consensus regarding thematic analysis and resolved discrepancies. We similarly identified challenges associated with the patient health priorities identification process, the development team's responses to these challenges, and subsequent refinements through thematic analyses of the development team's teleconferences.