Public Release: 

Yale approach bases decision-making on older adults' own health priorities

Yale University

New Haven, Conn. -- In a pilot project, researchers at Yale, New York University School of Medicine and Baylor College of Medicine have shown that an innovative approach to health care for older adults with complex health needs can be integrated into a real-world clinical practice. Known as patient priorities care, the approach helps patients and clinicians focus decision-making and health care on what matters most -- namely patients' own health priorities.

This approach could improve health care and outcomes for older adults with multiple chronic medical conditions, the researchers said. The research was published in two articles by the Journal of the American Geriatrics Society.

Most older adults who seek health care have multiple chronic conditions, and juggle multiple medical appointments, medications, and tests. The medications, often prescribed by different doctors, can cause troubling adverse effects. Older patients also vary in their health priorities, defined as both their health outcome goals (what they want from their health care) and their healthcare preferences (the healthcare activities they are able and willing to do).

To bridge the gap between what older patients value most in their lives and health, and the health care they experience, the Yale team and their project collaborators developed a novel method to help patients identify their health priorities and help clinicians translate these priorities into decision-making and care options. At a primary care practice in central Connecticut, the researchers trained facilitators to elicit detailed health information from participating patients in one or two structured conversations that together took about 30 minutes.

The patient information obtained by the facilitators went far beyond facts typically collected on a patient form. It described the patients' values, health goals, helpful versus burdensome care, perceptions of health trajectory, as well as a specific "ask" -- one problem the older adults considered most critical to achieving the health priorities that they most wanted their clinicians to focus on.

After documenting the patient priorities on a template, the facilitators transmitted the information through the electronic health record (EHR) to the primary care providers who used them to align care and treatment with what matters most to patients. These primary care providers and their partnering cardiologists were trained in how to consider the priorities in their decision-making and align their health care with these priorities. The research team and members of the primary care practice worked together to embed patient priorities care into the EHR and the clinical workflow.

At the end of the pilot project period, the research team found that the process of identifying, transmitting, and acting on patient priorities, while challenging, was achievable in a busy primary care practice.

While more research is needed to test the approach in different settings, said the investigators, the findings demonstrate that patients and clinicians can participate in current care planning based on patients' priorities.

"Improvement in patients' most-desired health outcomes and the avoidance of unwanted healthcare would support a move to patient priorities-aligned decision-making for older adults with multiple chronic conditions. Such a move holds promise for reducing care burden and fragmentation and ensuring that healthcare is focused on what matters most to this large patient population," said senior author Dr. Mary Tinetti, chief of geriatrics at Yale School of Medicine.

The research team also concluded that the process they developed could be adopted by other health teams. Tools and resources for patients, clinicians, caregivers, and health systems are available at patientprioritiescare.org.

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Authors of the first paper are Aanand D. Naik, Lilian Dindo, Julia Van Liew, Natalie Hundt, Lauren Vo, Kizzy Hernandez-Bigos, Jessica Esterson, Mary Geda, Jonathan Rosen, Caroline Blaum, and Mary E. Tinetti. Authors of the second paper are Caroline Blaum, Jonathan Rosen, Aanand D. Naik, Cynthia D. Smith, Lilian Dindo, Lauren Vo, Kizzy Hernandez-Bigos, Jessica Esterson, Mary Geda, Rosie Ferris, Darce Costello, Denise Acampora, Thomas Meehan, and Mary E. Tinetti.

The research was supported by grants from The John A. Hartford Foundation, Patient-Centered Outcomes Research Institute, The Gordon and Betty Moore Foundation, and The Robert Wood Johnson Foundation.

Citation: Journal of the American Geriatrics Society

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