Table 4.

Patient recommendations for the Patient Health Priorities Identification process

Theme	Recommendation Specifics
More frequent home visits	Monthly to bi-monthly in-home facilitator visits/telephone calls
Contact with facilitators should be flexible and determined by patient characteristics and need	Increase the number of contacts after a “trigger” event (e.g. hospitalization) Delivered in-home or over the telephone Individuals with higher need or limited social support would have more frequent contact
Select patients for participation in PHPI based on patient characteristics and need	Characteristics: More multimorbidity/higher mortality risk Recent illness Limited social support/financial support
Clarify the aims, process, and expectations of the PHPI	Differentiate facilitator visits from in-home annual exam or wellness check Clearly cover process of PHPI and priorities identification Discuss timeline of visits/expected outcomes
Follow-up	Schedule follow-up appointment with clinician within 1–2 weeks of facilitation
Reminders	Include written take-home notes, that lists patient-identified health priorities Encourage patients to take reminders to their follow-up clinician visit
Limit the number of forms patients are required to complete as part of the PHPI	More face-to-face contact Have research team collect patient health data when feasible
Involve family members throughout the PHPI process	Encourage family participation during facilitation visit Encourage family to accompany the patient to clinician visit
Facilitators should perform health-related clinical tasks in addition to identification of health priorities	Discuss patient medications, medical conditions, and make recommendations regarding healthcare