Personalized Health Care, an approach being developed at Duke University, focuses on personalized, proactive, patient-centered care. It seeks to remedy spending on chronic care by encouraging healthy behavior and planning. Patients are given the opportunity to engage with their own health by identifying areas in their life where they are motivated to make changes. In initial visits, physicians assess the patients’ risk including family history, genetic markers, lifestyle habits, and other biometric data during the appointment. Then, the physician and patient work to create a timeline for health improvement. Health coaches and nurses monitor the patients’ progress and help them meet their health goals.
Personalized Health Care is based on three key principles: personalized health planning (the clinical workflow), coordination of care, and rational reimbursement (changes in our organization of care required for the success of personalized health planning).
Personalized Health Planning
Personalized health planning (PHP) is the key feature of personalized health care as it anticipates the individual’s specific health needs and develops a coordinated means to achieve them. The PHP is developed collaboratively by the provider and the patient and utilizes comprehensive health risk assessment as the basis for both enhancing health and well-being and mitigating and tracking disease over time. Greater collaboration between patient and provider replaces the traditional physician-dominated dialogue with more effective patient-physician partnerships. The patient’s own needs and goals for health, wellness, and disease mitigation drive the planning process and nature of the plan. The PHP framework provides an operational care model for delivering personalized, proactive, patient-driven care to individuals with a diverse range of needs.
Five key steps outline the personalized health planning process:
- A member of the care team assesses the patient’s level of engagement. The patient completes a self-assessment of health needs, preferences, and goals.
- The clinician assesses the patient’s health status and health risks using the best available conventional, genomic, and other precision diagnostic tools. He/she identifies optimal risk-mitigation and therapeutic goals for the patient.
- The clinician and patient set shared goals, using the clinician’s health assessment and the patient’s self-assessment.
- The shared goals are incorporated into a personalized health plan. The clinician chooses appropriate metrics for monitoring progress, identified explicitly for the patient; an electronic medical record is used for data collection and tracking.
- The clinician coordinates care with the rest of the patient’s care team and arranges for appropriate follow-up.
For more details about Personalized Health Planning, see our piece in NEJM Catalyst.
Coordination of Care
Coordination of care includes collaboration among all relevant providers as well as continuity of care over time. Patients with one or more chronic disease often need care from different medical professionals, including doctors, nurses, pharmacists, physical therapists, or mental health providers in various care settings. With a larger team of health care providers and locations, there are inevitable transitions or transfers that occur between hospitals, nursing homes, small outpatient clinics, and the home. Studies have shown that such transitions can jeopardize the quality of care delivered and, in some cases, can jeopardize patient safety as a result of lack of communication, inaccurate or incomplete transfer of relevant health information, and poor follow up plans for patients after leaving the hospital. Researchers have estimated that inadequate care coordination was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions. Coordination of care is a key component of a prospective and preventative approach to health care that saves money, fosters optimal outcomes, and creates a better health care experience for the patient.
This video from UnityPoint Healthcare provides a short introduction to the concept of coordinated care as a means to improved health outcomes.
A rational reimbursement system that supports personalized health care planning and coordination of care across providers and time are a necessary component of this approach. A significant barrier to developing innovative ways to meaningful health care reform has been the perverse incentives of the reimbursement system which rewards complex interventions rather than the more labor intense solutions needed for health promotion and coordinated care. This current model for reimbursement, commonly referred to as fee-for-service, has created incentives for providers to focus on interventions and diagnostic testing that create the greatest margin, rather than the more holistic needs of the patient to manage their disease. The impact of changing health care reimbursement to facilitate better outcomes is beginning to stimulate interest in coordination of care and the development of best cost effective practices. Nonetheless, given the magnitude of the health care provider industry and its dependence on fee-for-service methodology, the conversion to a reimbursement system that rewards best practices will not emerge overnight.