Design and Implementation
This project qualified as exempt through the Duke University Institutional Review Board. The primary aim of this pilot was to examine the feasibility of implementing personalized health planning into primary care settings and to develop a workable process that is scalable and customizable to inpatient and outpatient clinics of varying sizes for different patient populations within the VHA. The pilot included 5 clinics in 2 geographic areas that were selected for their facility’s leadership support and desire to participate.
The VA Boston Healthcare System implemented personalized health planning at 3 primary care clinics: Jamaica Plain Primary Care, Jamaica Plain Women’s Health, and Quincy Primary Care. Three distinct PACTs participated in Boston, each composed of a medical doctor or doctor of osteopathy, a registered nurse (RN) or health technician, and a medical support assistant. The Sam Rayburn Memorial Veterans Center in Bonham, Texas, implemented personalized health planning at 2 clinics: the Hypertension Shared Medical Appointment and the Domiciliary Inpatient Primary Care. At Bonham, a medical doctor, pharmacist, RN, and an integrated mental health provider led the shared medical appointment (SMA) with guest presenters for individual appointments, depending on the topic covered. A RN and social worker implemented personalized health planning in the domiciliary.
After receiving training in the personalized health planning process, each of the clinics’ multidisciplinary PACTs incorporated their custom personalized health planning workflow into patient encounters. During the intake process of the clinic visit, the patient received a Personal Health Inventory (PHI) to determine health care priorities. The OPCC&CT developed the PHI as a whole-health self-assessment tool to help patients reflect on their health and lives, including core values, disparities between current and desired states, and preparedness to make behavioral changes to promote health.
The PHI assisted with framing this whole health approach to clinical care by expanding the definition of health to include more holistic elements of well-being, such as spirituality, personal relationships, emotional health, and personal development. A visual representation of the whole health domains termed The Circle of Health introduced this concept to the patient and assisted with goal setting (Figure 3).12
The PHI organized the patient’s input and was provided to the clinician to contribute to the development of the shared therapeutic goals and a final treatment plan. The PHP provided the tool to organize the goals, plans, and care following the visit and to connect the patient to additional resources within the VHA to support goal attainment through skill building and support. Each clinical site developed a mechanism to follow up with these patients either telephonically or with additional clinic appointments. The participating clinics implemented their customized version of personalized health planning for an average of 3 months.
Personalized health planning and accompanying tools were used primarily in routine ambulatory care visits. They were also used in the Bonham domiciliary clinic, which provides care for veterans with mental illnesses or addictive disorders who require additional structure and support. The purpose of the pilot was to determine whether personalized health planning could be used within this population. Given the small sample size and incompleteness of data collected, the Bonham domiciliary group was not included in the participating patient total. Across the other 4 clinics a total of 153 patients participated in the 3-month pilot study by establishing shared health goals and plans to meet them.
Results and Evaluation
Using a structured interview guide, a total of 6 small group interviews with participating clinicians were held (3 in Boston and 3 in Bonham, N = 18). Qualitative methods for research and evaluation were used to capture the depth of responses and to provide complex descriptions of the clinicians’ perspectives on the implementation of the personalized health planning process. Two researchers reviewed the transcripts to identify and code themes, and a third researcher reviewed the transcripts to confirm themes and resolve any discrepancies.
Analysis of the interview data revealed 9 core themes related to the feasibility, effectiveness, and future dissemination of personalized health planning. These themes, described below with exemplar data, include (a) patient engagement; (b) clinical assessment; (c) goal setting; (d) clinical workflow; (e) resources and support for veterans and clinicians; (f) Computerized Patient Record System (CPRS) integration; (g) patient-clinician relationship; (h) clinical outcomes; and (i) patient satisfaction.
The purpose of this study was to evaluate the feasibility of introducing personalized health planning within the workflows of the clinics that were participating. As a consequence of this, interviews were held with clinic staff rather than patients. However, the authors did obtain patient satisfaction data from 10 patients who received care from the hypertension SMA and responded to TruthPoint questions after their visit (Table).
Patient Engagement
A central tenant of personalized health planning is to engage patients in their health and health care. Findings revealed that clinicians at both sites perceived the PHP as an effective tool for integrating patients as robust members of the care team. Clinicians noted that by asking patients what was important to them, the patients felt more empowered to actively engage in the clinical encounter and to take responsibility for their health decisions. One pharmacist noted, “Patients are more empowered…when you change how you’re having your conversation with them that helps people start to recognize that they are an active participant [sic] and they can have an impact and can help with minimizing medicines or trying other things.”
Clinicians reported that including patients as active members in their care created a level of buy-in that motivated behavioral changes, because the patients identified behaviors they wanted to change vs the clinician telling them what they should or should not do. A nurse manager reported, “The key is that (the health goal) is coming from the patient…. Once it comes out of their mouth, they’re thinking about it and it’s not the clinician telling them what they should or shouldn’t do, but it’s helping them…identify something that’s important that will keep them into staying the way they want to, for the reasons that they want to.”
Clinical Assessment
The HRA tools are a vital part of the personalized health planning process, as they focus on preventive strategies that are most important for the patient.4 Clinicians reported using the PHI and additional HRA tools as part of the pilot program. The PHI is a self-assessment tool designed to identify psychosocial, behavioral, and environmental issues that can impact the patient’s care and health status. Most clinicians found that the PHI helped to solicit patients’ input on what was important to them and their health status while introducing the new approach to care. One nurse commented, “I found [PHI] very effective if I could actually sit down and review it with them to see what it was that was truly important to them and explain that this new approach is for a better understanding.”
Clinicians also found that the PHI helped focus the patient’s attention toward self-care areas that facilitated the shared goal setting process with the clinician. It moved the clinical encounter away from the chief health problems and toward identifying what is important to the patient and leveraging his or her intrinsic motivation to support health promotion via lifestyle modification.
Goal Setting
Shared goal setting is a critical component of personalized health planning. The clinician and patient must agree about realistic goals to improve the patient’s health. Clinicians reported that the goal setting stage was most successful when patients were invited to guide the process and offered the goals themselves; ie, when it was not just patient-centered but patient-driven.
“Setting a goal with a patient is pretty easy because people have an idea of what they should be doing and what they want to be doing,” one clinician reported. “They know their goal. So it’s a matter of just listening, really listening, and seeing what they want…. It’s not incongruous to get the medical goal and the patient goal to match.”
Patients were amenable to this collaborative approach to goal setting, and there was often commonality between the clinician’s goals and what was important to the patient. Occasionally, the patient set goals in seemingly unrelated areas that facilitated chronic disease management.
“One of our hypertensive patients wanted to work on things that are external that they felt are stressors that actually caused their blood pressure to be high,” a pharmacist recalled. “At the end of the day they wanted to control their environment better so that they could see if they could then be off of antihypertensives altogether. It appears that may be the case right now. That this individual has been able to accomplish that, which I thought was amazing, and since it’s still new, I’m still a little bit skeptical.... Is that possible? But if at the end of the day that is an outcome that we see from doing this, I think that’s wonderful.”
Clinicians reported that follow-up with the patient was a critical aspect of goal setting, because it improved accountability and helped track progress and health outcomes. However, due to the 3-month time limit of the pilot, there was insufficient time to get uniform data on the formalized follow-up systems developed by each clinic.
Clinical Workflow
Examining the feasibility of creating a process to incorporate personalized health planning into a busy primary care clinic was one of the major aims of this pilot. As such, issues of time, staff responsibilities, and use of the CPRS and other systems to facilitate the process were challenges that each clinic addressed in slightly different ways and with varying success. One method was to leverage the SMA for a group of patients with a common diagnosis to discuss their goals, provide accountability, and improve access to a medical team.
Another innovative approach was utilizing medical support administrators and health technicians to front-load some of the introductory information and patient education in the waiting room or during the intake process. Despite these efforts, some clinicians thought that the personalized health planning process might take longer than the traditional clinical encounter. One nurse manager commented, “I think it did affect the length of visits…it has made them a little bit longer.”
Resources and Support
The VHA has been undergoing a shift from an emphasis on tertiary care to include a greater focus on primary care. Part of this shift has been an investment in complementary and alternative medicine (CAM). The PHP helped clinicians explore what resources existed at their facility to support veterans in accomplishing their goals, including CAM. One nurse reported, “It made us look into other avenues that were actually available at the VHA that we didn’t even know we had…the acupuncture, the qigong, the voluntary services getting the veterans involved.”
Clinicians also identified the need for patient education in the concepts of whole health, personalized care, and patient involvement as necessary for moving the piloted approach forward. A nurse noted that “for [personalized health planning] to work well, [the patients] need more orientation and education upfront systemwide so that when they get into an appointment with us, we’re not starting at explaining the whole world view of partnership and doing things differently.”
Resources for clinicians were just as critical as resources for patients in facilitating the personalized health planning process. Specifically, most clinicians identified their own education and training in techniques to engage the patient in a meaningful way via motivational interviewing and health coaching complemented the personalized approach to care, particularly for shared goal setting,
CPRS Integration
The CPRS is an integrated, electronic patient record system that provides a single interface for clinicians to manage patient care as well as an efficient means for others to access and use patient information.19 The most commonly cited challenge in the pilot was the lack of available staff and time in the patient visit to complete the PHP while completing documentation requirements in CPRS.
One clinician stated, “For clinicians, the barriers…it’s time to get through the reminders and preventatives.” Clinicians reported that the process and the CPRS documentation were misaligned and lacked integration to coordinate care or support health planning. Moreover, clinicians reported that the data being collected did not support patient-centered care.
Patient-Clinician Relationship
A significant strength of personalized health planning was that it fostered a beneficial patient-clinician relationship that promoted greater depth of care. One clinician noted, “I think that it adds a more personalized dimension to the whole patient visit.” In addition to experiencing a deeper relationship with their patients, clinicians also expressed having higher levels of job satisfaction and relished the opportunity to connect with their patients in a more personal way.
