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

Discussion

The current study describes the development, refinement, and feasibility testing of a patient priorities identification process targeting older adults with multiple morbid conditions. Development and refinement benefited from having multiple user perspectives, including patients, facilitators, PCPs, and a multidisciplinary development team. Input from facilitators and patients during feasibility testing resulted in refinements drawn from clinical experiences.

Results of this study demonstrate that healthcare professionals can be trained to perform the patient priorities identification process as part of their clinical encounters. Furthermore, identification of patient health priorities is practical and feasible for older adults with multiple chronic conditions. Facilitators report that the patient priorities identification process is rewarding and enjoyable but requires training and formal feedback with point-of-care manuals and investment of time with each patient. Our experience suggests that facilitators can be drawn from various health professions (e.g., nurses and nurse practitioners, social workers, psychologists, physicians) with prior training in motivational interviewing or similar skills. Facilitators described the values clarification step as essential but challenging at times because patients are at various levels of readiness to engage with facilitators and their clinicians about their values, goals, and healthcare preferences. We adapted the facilitator manuals to offer prompts and concrete examples to encourage conversations about what matters most to patients. Facilitators felt that beginning with values clarification improved the reliability and usefulness of the patient health priorities identification process.

Refinements, based on user feedback, included adaptations to the facilitator training, patient and facilitator manuals, and patient priorities template to simplify the process and enhance acceptability and usefulness. In addition, facilitators used the steps described in Table 1 and Supplementary Figure S1 flexibly in terms of length, order, and emphasis to customize the process to each patient's readiness. Refinements to the content and structure of the template over time culminated in the version described in Supplementary Table S2. The integration of patient encouragement was a refinement that prepared patients to advocate for their health priorities with their clinicians.[44–46]

This work builds on a growing literature describing approaches that develop clinicians' communication skills for adults with serious or life-threatening illnesses.[13–15,47] A recent intervention targeting patients with a life expectancy of 2 years or less resulted in greater documentation of patient values and goals in the electronic medical record than in a usual care group.[15] The patient priorities identification process targets patients with broader illness trajectories that allow for a wider time horizon of goals and range of preferences. Prior case management interventions for frail older adults have effectively linked patient preferences to care plans,[48,49] although disease guidelines, not individual patient priorities, were the primary basis for care plan development in these case management models. Although building on earlier work, our project is the first to our knowledge to include a clinically feasible approach not limited to advanced illness or the end of life for identifying and linking each person's health outcomes goals with the health care they are willing and able to receive or participate in to help achieve those goals.

Eliciting and documenting the personal values of older, multimorbid adults is uncommon in routine care,[24] despite playing a central role in person-centered care.[24,45,47,50] Identifying what matters most (broad statements of patient values) using a structured process during routine encounters opens the door to understanding and framing specific health outcomes that patients are willing and able to achieve.[11,24] Values (broad statements of what matters most) are the precursors to identifying SMART health outcome goals.[1,11,24,47]

The current study has limitations. The sample was drawn from a limited geographic area, although more than half of participants had a high school education or less, supporting the acceptability of this process over a wide range of educational levels. It remains to be determined whether the process can be imbedded sufficiently in routine care to allow reassessment of patient priorities over time, as needed as health status changes. We are collaborating with PCPs to determine whether they find this information appropriate or useful. The availability of healthcare team members to facilitate the process is an impediment for health systems with fewer resources. The need for motivational interviewing skills may be a further limitation, although these skills are part of nursing, social work, and other health professions training. It is unclear how to ensure alignment of healthcare decision-making with patient health priorities and the eventual effect of eliciting patient priorities on longitudinal outcomes.

Despite these limitations, input from a multidisciplinary development team combined with feedback from patients, clinicians, and health literacy and patient advocate experts is a strength of this work. Conducting the study with practice-based clinicians in the context of a primary care service suggests that implementation of the patient priorities process in practice is feasible.

Implications and Next Steps

Our ongoing work includes ascertainment of patient and clinician perceptions of the process and evaluation of the effect on clinical decision-making and on patient, clinician, and health system outcomes. We are assessing the feasibility of the patient priorities care process in individuals with dementia. We will also test the process in additional settings to determine whether feasibility or acceptance differs according to educational level, ethnicity, or other factors. We are also exploring the role of payment innovations and value-based payments to cover facilitator and clinician time to identify patient priorities and provide priorities-aligned care. The patient priorities identification process will be disseminated as an online training program to prepare patient priorities facilitators and further spread the approach using tips and tools for clinicians without access to a facilitator.

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