Within our current healthcare environment, care plans are usually created by doctors and other health practitioners when we are their “patients”. The current popularity of patient-centered care is a very positive and welcome change from historical practices where the doctor and healthcare system was in control. However, we are not always patients. And when we are patients being treated for acute or chronic health conditions, care plans created for our treatment should be an integral part of our personal health journey. A person-centered care plan adopts this broader, long-term view for wellness that is guided by our personal team of doctors, therapists, family caregivers, and supportive friends.

We are developing a mobile app named My Care Guide that was conceived from the beginning to support person-centered care. My Care Guide is a unique app for iPhone and iPad that puts you at the center of defining and participating in health care planning that inevitably includes many detours, expected and unexpected, guided by many advisors during your personal journey.

Patient-Centered vs Person-Centered Care

When I first began research and mobile app development for care planning, I used the very common term “patient-centered care” to describe my approach for patient engagement with their care team. However, as I began to expand my scope to a more holistic and personal view for supporting our health and wellness, I decided that “person-centered care” was a better description. Searching on this new phrase yielded several research papers describing the benefits of person-centered care, and interestingly most of that research was produced by the geriatric care community, especially the American Geriatrics Society.

Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations. Person-centered care is an approach to meeting these aims in a way that assures the primacy of individuals’ health and life goals in their care planning and in their actual care. [1]

Their emphasis on persons having “multiple chronic conditions and/or functional limitations” is not limited to older adults. Indeed, my work on improving care coordination for Veterans can also be characterized by these same challenges. Young soldiers wounded in combat often live with functional limitations for the remainder of their lives, including physical injuries such as traumatic brain injury (TBI) or loss of limbs, and psychological challenges such as post-traumatic stress disorder (PTSD) or depression. A holistic, person-centered care plan can provide benefits for both young and older adults. See My Care Guide for Veterans for a more detailed description and Veteran-specific care plan scenarios.

Barbara Starfield, MD, a Distinguished Professor in the Department of Health Policy and Management at Johns Hopkins University describes a similar view of the benefits and need for holistic, person-focused care [2]:

Inherent in a person focus is the notion that attention to patients’ problems in the context of their multimorbidity (multiple coexisting diseases) is at least as important as appropriate care for their individual diagnoses. Good primary care is not the sum of care for individual diseases [emphasis added].

Person-Centered Care: A Definition and Essential Elements

Person-centered care definitionAn inter-professional panel of eldercare experts convened by the American Geriatrics Society (AGS), in collaboration with the University of Southern California (USC) and with support from The SCAN Foundation, released findings from a research project to better define ‘person-centered care’ and its key elements. Person-Centered Care: A Definition and Essential Elements, was published by the Journal of the American Geriatrics Society, Jan 2016. Their definition and list of essential elements provide direction and focus for development of our My Care Guide mobile app to improve care management and coordination.

“Person-centered care” means that individuals’ values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires. [1]

This panel of experts define the essential elements for person-centered care as follows:

  1. An individualized, goal-oriented care plan based on the person’s preferences.
  2. Ongoing review of the person’s goals and care plan.
  3. Care supported by an interprofessional team in which the person is an integral team member.
  4. One primary or lead point of contact on the healthcare team.
  5. Active coordination among all healthcare and supportive service providers.
  6. Continual information sharing and integrated communication.
  7. Education and training for providers and, when appropriate, the person and those important to the person.
  8. Performance measurement and quality improvement using feedback from the person and caregivers.

Practical Support for Person-Centered Care

My Care Guide is a mobile app for iPhone and iPad that puts you at the center of defining and participating in a person-centered care plan guided by your personal team of doctors, therapists, and other caregivers. My Care Guide is based on three complementary technologies that are uniquely suited for putting the person at the center of wellness and care planning: HL7 FHIR®© standard for EHR interoperability, CDS Hooks for providing real-time guidance on your progress, and the Apple CareKit™ and HealthKit™ frameworks for tracking and completing your care plan tasks. Person-centered care for women, with initial focus on maternity care, is the first clinical application for My Care Guide app pilot testing.

Additional examples of person-centered care that could be supported by My Care Guide include:

  • Managing chronic conditions (e.g. Diabetes, Hypertension, or Congestive Heart Failure)
  • Pediatric and family care
  • Surgery preparation and recovery (e.g. knee replacement)
  • Behavioral health care (e.g. Depression, PTSD, substance abuse)
  • Palliative care and hospice

References

  1. Person-Centered Care: A Definition and Essential Elements, Journal of the American Geriatrics Society, Jan 2016.
  2. Is Patient-Centered Care the Same As Person-Focused Care?,The Permanente Journal, Spring 2011.
  3. What is person-centered care and why is it important?, Health Innovation Network, South London, http://www.hin-southlondon.org