Aligning Care With Patients’ Priorities: An Improved Approach to Clinical Decision-Making

Family physicians care for increasingly complex patient populations, including older adults, who make up approximately 40% of a typical family medicine practice.¹ Among older adults, 75% have multiple chronic conditions.² Despite this population’s exclusion from most clinical trials, their care typically relies on the application of clinical guidelines designed for single diseases. In addition to offering uncertain benefit, single-disease guidelines may worsen a coexisting condition.³ For example, using beta-blockers to treat heart failure may be at cross-purposes with managing depression. Moreover, older adults with multiple chronic conditions may receive recommendations for services — such as labs, imaging, medications, and self-care tasks — that are unwanted, unhelpful, or burdensome. In short, care based solely on single-disease guidelines often does not align with the outcomes individual patients want most from their health care.^4,5

Patient Priorities Care (PPC) is an evidence-based approach for identifying and aligning care with patients’ health priorities (Figure 1).^6–9 The approach was developed under the leadership of two of the authors (Naik and Tinetti) with grants from organizations including The John A. Hartford Foundation and the Department of Veterans Affairs, and with input from clinicians across several disciplines, older adults, care partners, and health system experts. PPC is not a discrete model but rather an open-access approach to decision-making and communication that can be integrated into any clinical setting. All PPC resources, including those shared in this article, are freely available.¹⁰

In several studies, the PPC approach resulted in less unwanted care and fewer burdensome health care tasks.^6–8 It was also associated with increases in wanted care aligned with patients’ priorities, such as community supports and rehabilitative services.^7,11 Clinicians and patients have found this approach to be feasible and acceptable.⁶, ^12,13 Despite concerns about unintended consequences, focusing on patient priorities does not result in more emergency department or hospital visits or worsened disease-specific metrics.^8,9 While the PPC approach is appropriate for all patients, it is particularly important for older adults with multiple chronic conditions, functional limitations, or life expectancies between two and 10 years for whom disease guideline-based care may be burdensome, harmful, and of uncertain benefit, and for whom end-of life-care is not yet indicated.^14,15

All clinical team members — including physicians, advanced practice clinicians, medical assistants, social workers, and care managers — can participate in patient priorities-aligned care. Although family medicine practices likely already engage in some elements, PPC frames all clinical decision-making and communication among all members of the health care team over time in a structured and reproducible way. This approach shifts the focus of decision-making from siloed diseases to the outcomes that matter to each patient. Seeing the steps written out (below) may make the process seem complex and time consuming. However, many of these steps are implicitly, if not consistently, used by primary care clinicians. The PPC approach makes the process explicit and thorough — and, thus, more effective. Most clinicians report that it becomes quicker, easier, and more natural with experience.