As a geriatric physician, I've witnessed firsthand the challenges that arise when older patients and their families must juggle multiple chronic conditions.
Patients are overwhelmed by medical appointments, medications, tests and procedures, and often discouraged by conflicting recommendations from their clinicians. Care can be fragmented, burdensome and even harmful. It is estimated 1 in 5 Medicare beneficiaries experience "guideline-driven harm," as their clinicians prescribe disease-specific medications that may interact in dangerous ways. People with multiple diseases and conditions also have different opinions on the health and life outcomes are most important to them.
Meanwhile, clinicians are also frustrated. Lack of evidence for this large population of patients with multiple conditions means providers are often uncertain about the best treatment. And trying to communicate with other clinicians, many of whom they don't know, can be frustrating and time-consuming. Clinicians become discouraged when the lines of communication get crossed or patients don't adhere to their recommendations.
Imagine if we could help older patients with multiple chronic conditions achieve the health outcomes they most desire, while reducing fragmentation and frustration among their clinicians. An approach now being tested in Connecticut aims to do just this.
Patient Priorities Care was developed by clinicians, patients, caregivers, health system leaders and payers throughout the country. The principles and activities that define Patient Priorities Care will be disseminated nationally. This approach involves aligning care among all a patient's clinicians with what matters most to that patient—the health outcomes they want, given the healthcare tasks they are willing and able to complete. It is a distinct shift away from disease-based decisionmaking and care, helping patients identify and explain their priorities so their clinicians can work together to meet them.
As an example, Mr. Alvarez, 91, is one of the patients at the clinic where we're testing Patient Priorities Care. He lives with his daughter. Until recently he met his friends regularly for breakfast and good conversation. But then he stopped going. Both he and his daughter expressed concerns about his isolation.
Mr. Alvarez's primary-care provider thought this decrease in socializing and mobility was because of his hip pain, and thought surgery might be the solution. However, after Mr. Alvarez discussed this possibility with the orthopedist his primary-care provider referred him to, he decided he did not want surgery.
The primary-care provider wasn't sure how to help Mr. Alvarez. He recommended a consultation with another healthcare team member who was trained to help patients identify their health priorities, so they could better understand what was most important to him.
Mr. Alvarez met with Katherine to discuss his health values and goals. They identified what mattered most: staying connected with family and getting out of the house to meet his friends. He noted that although his hip bothered him, the main reason for his lack of mobility was dizziness. Katherine helped him articulate a specific goal: "I want to feel less dizzy and have less hip pain in the morning so I can go out to breakfast and see my friends."
The primary-care provider was surprised to discover that Mr. Alvarez had specific, actionable goals that they could work on together. Together they agreed on trials of stopping one medication at a time to see if his dizziness improved enough that he could meet with his friends again. With his primary-care provider's guidance, Mr. Alvarez chose to start by decreasing one medication because he felt it made him tired as well as dizzy. Together, they are working out a series of changes to help meet his goals.
In our project, patients like Mr. Alvarez are reporting a better understanding of what they want from their healthcare and what they need to do to get there. They say they feel more confident in participating in decisions about their care. Meanwhile, clinicians think it clarifies care options and results in more consistent care. Knowing what matters most to a patient helps them discuss treatment options in the face of uncertainty.
Participating clinicians also report having better communication with their colleagues because they are all focused on accomplishing the same health outcomes for their shared patients. Knowing a patient's priorities helps them explain the importance of adhering to treatments based on what is most meaningful to the patient, and serves as a guide when making treatment decisions with the patient.
We will continue the pilot project through August. Results from this pilot are helping us learn how to best incorporate it into real-world workflows and understand what both patients and clinicians can do to ensure that the care given helps meet each patient's health priorities. Patient Priorities Care offers a unique opportunity to improve how we care for older patients, while improving the experience for their clinicians. Together, we can build a better way to deliver healthcare.
Dr. Mary Tinetti is a professor of medicine and public health and chief of geriatrics at the Yale School of Medicine. For more information about Patient Priorities Care, visit patientprioritiescare.org
