Clinical Review

Personalized Health Planning in Primary Care Settings

Personalized health planning can be operationalized as a health care delivery model to support personalized, proactive, patient-driven care.

Fed Pract. 2016 January;33(1):27-34

Author(s):

Leigh Ann Simmons, PhD, MFT

Connor D. Drake, MPA

Tracy W. Gaudet, MD

Ralph Snyderman, MD

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References

1. Anderson G. Chronic care: making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation; 2010.

2. Anderson G, Horvath J. The growing burden of chronic disease in America. Public Health Rep. 2004;119(3):263-270.

3. Dinan MA, Simmons LA, Snyderman R. Commentary: Personalized health planning and the Patient Protection and Affordable Care Act: an opportunity for academic medicine to lead health care reform. Acad Med. 2010;85(11):1665-1668.

4. Snyderman R, Yoediono Z. Prospective care: a personalized, preventative approach to medicine. Pharmacogenomics. 2006;7(1):5-9.

5. Snyderman R. Personalized health care: from theory to practice. Biotechnol. 2012;7(8):973-979.

6. Burnette R, Simmons LA, Snyderman R. Personalized health care as a pathway for the adoption of genomic medicine. J Pers Med. 2012;2(4):232-240.

7. Simmons LA, Dinan MA, Robinson TJ, Snyderman R. Personalized medicine is more than genomic medicine: confusion over terminology impedes progress towards personalized healthcare. J Pers Med. 2012;9(1):85-91.

8. Pelletier LR, Stichler JF. Patient-centered care and engagement: nurse leaders' imperative for health reform. J Nurs Adm. 2014;44(9):473-480.

9. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.

10. Simmons LA, Wolever RQ, Bechard EM, Snyderman R. Patient engagement as a risk factor in personalized health care: a systematic review of the literature on chronic disease. Genome Med. 2014;6(2):16.

11. Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med. 2012;27(5):520-526.

12. U.S. Department of Veterans Affairs. VA Patient Centered Care. U.S. Department of Veterans Affairs Website. http://www.va.gov/patientcenteredcare. Updated October 30, 2015. Accessed December 3, 2015.

13. Gaudet T. The Transformation of Healthcare. Paper presented at: 27th Annual Voluntary Health Leadership Conference; 2014; Tucson, Arizona.

14. U.S. Department of Veterans Affairs. VHA Strategic Plan FY 2013-2018. U.S. Department of Veterans Affairs Website. http://www.va.gov/health/docs/VHA_STRATEGIC_PLAN_FY2013-2018.pdf. Accessed December 3, 2015.

15. U.S. Department of Veterans Affairs. Blueprint for excellence. U.S. Department of Veterans Affairs Website. http://www.va.gov/health/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed December 3, 2015.

16. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38-48.

17. Simmons LA, Wolever RQ. Integrative health coaching and motivational interviewing: synergistic approaches to behavior change in healthcare. Glob Adv Health Med. 2013;2(4):28-35.

18. Snyderman R, Dinan MA. Improving health by taking it personally. JAMA. 2010;303(4):363-364.

19. U.S. Department of Veterans Affairs. Computerized Patient Record System (CPRS) User Guide: GUI version. U.S Department of Veterans Affairs Website. http://www.va.gov/vdl/documents/Clinical/Comp_Patient_Recrd_Sys_(CPRS)/cprsguium.pdf. Published November 2015. Accessed December 3, 2015.

20. Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Healthc Pap. 2005;5(4):10-24.

21. Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. JRRD. 2011;48(9):1119-1128.

22. Whellan DJ, Gaulden L, Gattis WA, et al. The benefit of implementing a heart failure disease management program. Arch Intern Med. 2001;161(18):2223-2228.

23. Edelman D, Oddone EZ, Liebowitz RS, et al. A multidimensional integrative medicine intervention to improve cardiovascular risk. J Gen Intern Med. 2006;21(7):728-734.

24. Wolever RQ, Dreusicke M, Fikkan J, et al. Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial. Diabetes Educ. 2010;36(4):629-639.

25. Yang NY, Wroth S, Parham C, Strait M, Simmons LA. Personalized health planning with integrative health coaching to reduce obesity risk among women gaining excess weight during pregnancy. Glob Adv Health Med. 2013;2(4):72-77.

26. Musich S, Klemes A, Kubica MA, Wang S, Hawkins K. Personalized preventive care reduces healthcare expenditures among Medicare advantage beneficiaries. Am J Manag Care. 2014;20(8):613-620.

27. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients' 'scores.' Health Aff. 2013;32(2):216-222.

Health care has become increasingly unaffordable in the U.S., yet it remains ineffective in preventing or effectively treating chronic diseases.^1,2 Given the increasing burden of chronic disease on the American health care system, there is an effort to shift the practice of medicine away from its reactive, disease-oriented approach to a more sustainable proactive model.^3-5

Personalized health care (PHC) is an approach to the practice of medicine where prediction, prevention, intense patient engagement, shared health care decision making, and coordination of care are essential to cost effectively facilitate better outcomes.^3,5-7 Greater collaboration between patient and clinician replaces the traditional clinician-dominated dialogue with more effective patient-clinician partnerships.^8,9 Patients’ knowledge, skills, and confidence to manage their health care have been linked to improved health outcomes, lower costs, and greater satisfaction with health care experiences.^10,11

Personalized health care has been proposed as a means to achieve better patient engagement as part of an aligned, proactive clinical approach. At the heart of PHC is personalized health planning, wherein the patient and clinician develop shared health-related goals and a plan to achieve them.³

The VHA, the largest integrated health care system in the country, is on the vanguard of incorporating tenets of PHC into its delivery model. In 2011, the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) was founded to “oversee the VHA’s cultural transformation to patient-centered care.”¹² This undertaking represents “one of the most massive changes in the philosophy and process for health care delivery ever undertaken by an organized health care system.”¹³

The primary goal of the VHA’s strategic plan for 2013 to 2018 is to provide veterans personalized, proactive, patient-driven health care.¹⁴ The intention of this approach is to engage and inspire veterans to their highest possible level of health and well-being. A personalized approach requires a dynamic customization of care that is specifically relevant to the individual, based on factors such as medical conditions, genome, needs, values, and circumstances. In addition to being personalized, this approach must be proactive, and therefore, preventive and include strategies to strengthen the person’s innate capacity for enhancing health.

The third distinction of this new model health care is that it is patient-driven, rooted in and driven by that which matters most to people in their lives and aligns their health care with their day-to-day and long-term life goals.¹⁵ The latter may be the most critical of the 3 tenets, because a personalized, proactive approach that is not driven by an engaged and inspired individual will be unlikely to achieve adherence, let alone the highest level of health and well-being.

The VHA is uniquely positioned to optimize health and well-being for veterans due in part to a systemwide emphasis on training providers to promote and support behavior change through approaches including health coaching and motivational interviewing. These synergistic approaches used widely by clinicians throughout the VHA are influenced by the transtheoretical model (ie, the stages of change theory), which considers patients holistically and helps them identify intrinsic motivation to improve their health behaviors.^16,17 The transformation occurring in the VHA is intended to shift the current disease-centric medical model to an approach that optimizes the health of veterans through patient-clinician engagement, health risk assessment (HRA), shared health goal creation, and a coordinated plan to attain them.^12,13

Personalized Health Planning

In recognition of the need to deliver care that emphasizes prevention and coordination, the patient-centered medical home, patient-aligned care teams (PACTs), and the chronic care model were developed. All of these embrace concepts of patient engagement, shared decision making, and team-based care. However, none of these approaches have outlined a clinical workflow that systematically and proactively operationalizes these concepts with the creation of a risk-based personalized care approach. Personalized health planning provides a clinical workflow that operationalizes all these features (Figure 1).

Of central importance is the creation of a personalized health plan (PHP), which the patient and clinician develop collaboratively. The plan serves to organize and coordinate care while engaging the patient in the process of care delivery and appropriate self-management of health.^3,5 This approach promotes personalized and proactive care that values the individual and fosters meaningful patient self-awareness and engagement through shared decision making.⁷

The personalized health planning process is composed of several key components (Figure 2).

It begins with a HRA and a comprehensive health evaluation whereby the clinician assesses the patient’s health through physical examination, family history, diagnostic testing, available biometric data, and tools to gauge the health status and health risks for the individual.⁴ In parallel, patients conduct a whole health self-assessment, which helps elucidate the importance of their health to their life’s purpose and to determine area(s) where they are motivated to make behavioral change. Based on the clinical assessment and the patient’s own health evaluation, the clinician prioritizes the health risks and identifies therapeutic goals needed to mitigate them.

With this information, the clinician develops a preliminary therapeutic plan to meet these goals and discusses this plan with the patient. The next component is the synthesis of the clinician’s goals and/or treatment plan with the priorities of the patient to establish shared clinician-patient goals. This is followed by the establishment of the PHP, which consists of the agreed upon shared clinician and patient goals, a therapeutic and wellness plan to meet them, metrics for tracking progress, consults and referrals, and a time frame for the patient to achieve the health goals.

The final component is coordination of care and a formalized follow-up system in which the health care team monitors the patient’s progress and provides support by revisiting or updating the PHP at intervals determined by the provider, based on the level of monitoring required by the patient’s health status. This approach invites the patient to become an empowered member of the care team by creating a patient-clinician partnership and providing a model for delivering personalized, proactive, patient-driven care to individuals with a diverse range of needs.^4,5,18