Durham VA PHP in Primary Care

Introducing a model of patient-centered care for improving Veterans’ primary care experience

Project Summary

Personalized Health Planning (PHP) in Primary Care is one of three implementation modalities at the Durham VA Medical Center that was funded by the 2016-2018 Whole Health Design Site grant. PHP in Primary Care utilizes the Veteran Health Administration’s Patient Aligned Care Team (PACT) model to foster patient-centered primary care delivery. The program introduces Veteran patients to the process of completing a Personal Health Inventory (PHI), a comprehensive analysis of health status and goals that includes:

  1. Self-assessment of health status
  2. Patient Activation Measure (PAM) ®
  3. Personal SMART (Specific, Measurable, Action Oriented, Realistic, Timed) goals

Together with their providers, patients then synthesize their priorities and goals with their provider’s health assessment to create shared SMART goals in a Personal Health Plan. A clinician will then contact the Veteran for follow-up approximately four weeks after their clinic visit to survey Veteran experience, goal progress, and recollect their PAM score. Information from the PHI, PHP, and follow-up is added into the patient’s EMR in efforts of care continuity.


  • Assist Veterans in completing the items in a PHI to provide measurable health goals
  • Integrate the PHI and PHP into the PACT’s clinical workflow with minimal disruption to the clinic visit
  • Sustain Veterans’ goal progress and positive health behavior changes by creating a living personal health plan with follow-up

Contribution to Practice

  • Evaluate PHI, PHP, and follow-up processes in an active primary care clinic setting
  • Inform primary care providers of Veterans’ current awareness and assessment of their health and health goals
  • Collect measurable results of Veteran goal progress, patient activation, and experience


Meagan Cannady at meagan.cannady@duke.edu