Clinical Review

Personalized Health Planning in Primary Care Settings

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Clinicians also reported that patients seemed more satisfied with the experience. One nurse commented, “They really respond to it very well when they figure out that you care about them as a whole… it’s not just about the disease process anymore.”

Clinical Outcomes

Clinicians reported a number of positive health outcomes during the pilot. One physician reported, “I have a patient, he had a follow-up today, a 29-year-old veteran, who was 260 pounds 5 months ago, and he’s 230 pounds today. He comes in monthly to see the nurse to let us know he’s doing it.”

The same physician also shared a similar transformation in a patient as a result of personalized health planning. “We had another one yesterday, 4 months ago his [hemoglobin] A1c was 10.3%. It was 7.2% yesterday, and [his weight was] down 20 pounds.” In addition to positive clinical outcomes, patients made changes in areas of their health that they identified as important through the PHI, although these areas are not typically discussed in a clinical visit.

Patient Satisfaction

Although the overall goal of this pilot was to determine the feasibility of a clinical workflow embracing personalized health planning, data on patient satisfaction were collected from patients receiving care in the Hypertension Shared Medical Appointments Program at Bohnam. Ten patients were seen over the course of 5 visits. At each visit, they were asked to rate their satisfaction (Table).

Overall, patients were highly satisfied with their experience and the care they received: 91.7% reported exploring what they wanted for their health and setting shared goals; 100% reported that their providers truly listened to their needs and treated them with respect and dignity; and 97.2% reported that their experience was better than a traditional office visit. One participating physician noted that higher levels of patient and provider satisfaction are a product of this type of patient engagement. “I also think that looking at patient and provider satisfaction, the visits feel more meaningful, and there’s a better relationship built through this discussion,” he noted. These findings demonstrating increased satisfaction further suggest the benefits of personalized health planning approach.

Discussion

In 2012, the VHA National Leadership Council convened a Strategic Planning Summit to set goals and objectives to help the VHA be at the vanguard of a movement toward a more proactive health care delivery model. The first of 3 goals developed was to provide veterans personalized, proactive, patient-driven health care.13 It is becoming increasingly clear that truly affecting health and health outcomes requires motivated, engaged, and informed patients with a care delivery approach that provides ample opportunities for patient involvement and input in health care decision making.10,11

The OPCC&CT has ongoing initiatives driving innovation, research, education, and deployment across the system to set the stage for personalized, proactive, patient-driven care.20 Some of these innovations include clinician education in the concept of whole health; health coaching; group-based, peer-led approaches; and the expansion of CAM such as mind-body approaches, qi-gong, massage therapy, yoga, and acupuncture.21

The primary aim of the Whole Health in Primary Care Project was to determine the feasibility of using personalized health planning as the operational model to deliver personalized, proactive, patient-driven care. The decision was made to integrate personalized health planning into ongoing clinical operations rather than design clinical pilots de novo. This had the advantage of speed in starting the project but limited the ability to create an optimal workflow from scratch. Given the time and resources available for this study, it was not possible to obtain quantitative data particularly as it related to quantifying clinical outcomes.

Despite these limitations, early indications suggest that the personalized health planning process can serve as the operational clinical working model to enable personalized, proactive, patient-driven care in a variety of primary care settings. As noted by one nurse manager, preparing the personalized health plan made the initial visit “a bit longer.” However, after the first visit, monitoring health risk abatement and goal achievement is akin to what is currently done by reviewing problem lists. Thus, although the personalized health planning experience is just beginning, clinicians noted that it fostered a beneficial patient-clinician relationship. This deeper relationship between the patient and the clinician may be the most powerful signal that the process is worthwhile.

This pilot provided valuable information related to the implementation of a clinical workflow redesign, an initial step toward developing an optimized operational model of the PHP process. Additionally, although it is not yet possible to quantify the clinical impact of the personalized health planning, anecdotal evidence suggests its positive potential. Clinicians reported that patients were successful in managing a multitude of common chronic diseases, including weight loss, high blood pressure management, reduction of A1c, and improved sleep habits.

These findings compare with studies using similar approaches that demonstrated their value in the treatment of congestive heart failure, cardiovascular disease risk, type 2 diabetes, and postpartum weight retention.22-25 A growing body of evidence continues to affirm that a primary care model designed to deliver individualized care focused on improving health and an augmented patient-clinician relationship results in significant savings, primarily from reduced medical expenditures.26

This pilot provided an important opportunity to learn how to improve the effectiveness of personalized health planning and how to scale it. The experiences in Boston and Bonham demonstrated that personalized health planning can be integrated into diverse primary care settings with PACTs. The authors suggest that the knowledge gained from this project should be incorporated into new pilots at various clinical settings to determine the usefulness of the PHP for clinical indications beyond primary care. Specialty care clinics, home-based primary care services, and telehealth programs would be potential clinical applications for such pilots.

New pilots should be designed de novo and be of sufficient length to gain quantitative data on patient activation and clinical outcomes. Furthermore, future studies of personalized health planning should obtain input from the patient using Likert scales, surveys, and focus groups to gauge and quantify patient satisfaction and outcomes with the approach. Since patient engagement and better understanding of patients’ holistic needs are central to development of the PHP, patients need to be educated about this new approach to care and their active role in it.

The choice of the tools, including the HRA instrument, materials for orienting patients to their more active role in their care, the PHI, the PHP template to document shared goals, and other avenues used to engage patients, require refinement to improve their clarity, effectiveness of conveying the intended information, and ease of use. These studies demonstrated the vital need to address the best means to engage patients in understanding the value of their health to them since the clinician visit is likely to be an opportune teaching moment. Initial observations suggested that patients respond with different degrees of enthusiasm when given the opportunity to be more engaged in their care. Future pilots should clarify whether these differences stem from (a) how the invitation is presented; (b) individual differences in personality and preferences; (c) perceived clinical needs; or (d) unfamiliarity with the collaborative personalized health planning process.

The alignment of personalized health planning with outcomes data in the CPRS is essential for widespread adoption. Importantly, incentives and performance metrics will need to be redesigned to support the intended outcomes of using personalized health planning in clinical care. To that end, further investigation into the potential for cost savings associated with personalized health planning use is warranted, especially given studies that suggest high levels of patient engagement result in lower health care utilization expenditures.27

Additionally, wherever personalized health planning is initiated, employees across all levels of the system would benefit from training in patient engagement techniques and other means of attaining behavioral change. This would facilitate more effective use of time during the clinical visit and improve both the patient’s and the clinician’s satisfaction. Indeed, preliminary data indicate that this approach in a SMA setting is greatly valued by the patients.

Conclusions

The Whole Health in Primary Care Project was conducted to determine the feasibility of personalized health planning as the basis for primary care designed to facilitate personalized, proactive, patient-driven care. The pilot demonstrated that personalized health planning could be operational in VHA clinical settings and used to enhance patient-clinician engagement, establish shared health goals, and increase patient satisfaction. The personalized health planning process also provides a framework for the rational introduction of new capabilities to enhance prediction, clinical tracking, coordination of ancillary services, and clinical data collection. Future research should validate the efficacy of personalized health planning within both the VHA and health systems nationwide. Such research has the potential to refine this process so it becomes a key part of a personalized, proactive, patient-driven delivery approach.

Acknowledgements
We gratefully acknowledge the assistance of Cindy Mitchell at Duke University Medical Center with the editing and preparation of this manuscript. We also gratefully acknowledge the participation of the providers and patients at VA Boston Healthcare System and Sam Rayburn Memorial Veterans Center. Funding for this project was provided by VA777-12-C-002 to the Pacific Institute for Research and Evaluation through subcontracts to Ralph Snyderman, MD, and to the Duke University School of Nursing (Simmons PI.)

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