Table 2.
Key care and digital components, described in terms of the capabilities they offer in support of the person-centered, integrated, and proactive care. We have mapped each PIP-element to statements of care system capability for each of the 4 generic stages of an individualized patient pathway.
| Care components | Goals | Plans | Delivery | Evaluation | |
| The person-centered care system… | |||||
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Care | ...declares Person-centered care as an ideal and explores “what matters to me?” and “patient values, needs, and preferences.” | ...uses “What matters to me?” to negotiate realistic goals and create a care plan. | ...includes patient capabilities aligned with “What matters to me?” in care delivery. | ...asks for patient feedback/ PROMsa |
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Digital support | ...offers access to digital health information/ electronic health record and supports the formulation of “what matters to me?” | ...offers digital sharing of: What my carers should know about me. | ...includes the patient in virtual care delivery and team exchanges. | ...encourages digital feedback from patients, including PROMs. |
| The integrated care system… | |||||
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|
Care delivery | ...identify condition- or function-specific goals that support “what matters.” | ...combines condition/function-specific pathways into a whole person care plan for all conditions. | ...allocates resources to care plan, to show who does what when. | ...follow up to identify needs for adjustment of care plans or delivery. |
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Digital support | ...digitally identifies potential professionals to contribute to care plan development aligned with “what matters to me?” | ...provide tools to build a personalized digital evidence-based care plan, with workflow optimization to show: who does what when. | ...shares the care plan digitally across providers and offers tools for virtual team communication (video, messages, and chat). | ...triggers an alarm in case of gaps in critical care delivery. |
| The proactive care system… | |||||
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|
Care delivery | ...identifies high-risk subpopulations, their individual high-risk scenarios over time and aligns focus on risk with ”What matters to me?“ | ...supports risk monitoring, self-managed or professional follow-up, in alignment with ”What matters to me?“ | ...offers low threshold response (self-managed, office or home visits) to uncertainties, emergencies, and alarms. | ...learns and adjusts goals and plans in light of undesired events and ”What matters to me?“ |
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Digital support | ...offers an algorithm-based risk-stratification tool to identify high-risk populations and their individual risk scenarios over time. | ...offers personal digital health apps and sensors that monitor risk and provide digital contingency plans in case of uncertainty, emergencies, or alarms. | ...provides digital decision support and low-threshold e-visits in case of uncertainty, emergencies, or alarms. | ...is a learning health care system improves prediction and action plans in light of undesired events. |
aPROMs: patient-reported outcome measures.