Developing a model of proactive, personalized, and person-centered health assessment and education in primary-care based shared medical appointments at Lincoln Community Health Center (LCHC)

Project Summary

Personalized Health Planning in Shared Medical Appointments (PHP SMA) at Lincoln Community Health Center in Durham is a primary-care based program for patients who have been diagnosed with type II diabetes. Eight sessions held over the course of four months incorporate both health assessment and educational components. Participants meet one-on-one with a provider to complete a Personalized Health Plan (PHP) and as a group engage in discussion, interactive activities, mindfulness meditation, goal-setting, and educational content on a range of topics to improve self-care behaviors and health outcomes. At the conclusion of the program, patient participants will have taken steps towards improving management of their type II diabetes in addition to building strategies of effective self care that will prevent deterioration of health through a unique model of tailored behavioral support.


  • Provide comprehensive diabetes education coupled with peer support and mindfulness meditation instruction
  • Synthesize the provider’s goals and treatment plan with the priorities and goals of the patient to create shared goals
  • Develop a treatment plan based upon the patient’s health status, health risks, provider goals, and patient and provider shared goals
  • Track goal progress through a system of behavioral support, care coordination, and accountability for the patient to maintain between sessions

Contribution to Practice

  • Examine the feasibility of implementing evidence-based personalized health planning in the context of a Shared Medical Appointment for patients in a primary care-based setting
  • Collect preliminary efficacy and cost effectiveness data on the PHP framework in Shared Medical Appointments for primary care-based setting


Heather Batchelder –