Table 2.

Challenges to Implementing Patient Priorities Care (PPC)

Workflow Challenges	Strategies to Address Challenges and Improve Workflow
PCPs and cardiologists have limited time for training and ongoing collaborative learning	Leadership support; PCPs and cardiologists are reimbursed for training time Twice-monthly 15- to 20-minute collaborative learning sessions at lunch (PCPs) and monthly before clinic (cardiologists) and during in-person meetings
Clinicians unclear about identifying appropriate patients	Administrative identification with PCP review; clinicians and implementation team discuss in monthly meetings
Patient invitation process slow Clinicians concerned that eliciting patient priorities increases burden for complex patients	Instituted brochures and posters for clinician offices; scripts for PCPs; discussed at monthly meetings; clinicians receive list of eligible patient upcoming appointments Comments from patients regarding how much they liked PPC were helpful, as was feedback from other clinicians
Clinicians differ about how to initiate PPC after patient completes priorities identification	Some clinicians preferred to devote a visit to initial discussion of PPC; others incorporated the discussion in a regular visit. Both options are reasonable
Clinicians concerned about patient copayments if extra visit and about reimbursement for extra time	PCP visit can be incorporated into an extended scheduled visit; recent Centers for Medicare and Medicaid Services codes for advanced care planning and chronic care management can be used.
Clinicians don’t document priorities-aligned decision-making	Discussed at monthly PCP clinician/implementation team meetings (every 2 months for cardiologists); feedback report provided to clinicians
Workflow and communication between PCP and cardiology offices difficult to implement	Cardiology and PCP offices work together to identify PPC patients before they see cardiologist. Flag for PPC patients implemented in cardiologists’ EHR Referral form emphasizes question PCP wants cardiologist to address; priorities template and PCP note faxed to cardiology offices
Clinicians may not address patient priorities at follow-up visits.	Issue emphasized in monthly (PCP) and every 2 months (cardiologist) meetings
Decision-making challenges	Strategies to Address Challenges and Support PPC Decision-making
Clinicians (PCPs and cardiologists) need to agree to participating in PPC	Healthcare system leadership support; PPC discussed at clinician educational meetings; clinical champions engaged; nationally prominent PCPs and cardiologists helped develop and endorse PPC; national experts in practice change and clinician training engaged in the training; activate patients and caregivers through training to take ownership of health priorities
Some clinicians thought they were already providing care aligned with patient goals and priorities	Reframe approach from being different from usual care to being a systematic method for providing person-centered care
Culture, clinical interventions, quality metrics, and payment remain driven by evidence-based disease guidelines and individual disease-based metrics continue to drive culture, clinical interventions, quality metrics, and payment	Training included discussion of some usual measures relevant to patients with MCCs, such as Patient-Centered Medical Home metrics (goals and burden). It is necessary to partner with national organizations to develop quality metrics and guidelines to support patient priorities aligned decision-making.
Clinicians lack experience in discussing uncertainty, trade-offs, and clinical trajectories, and in addressing patient-provider and provider-provider disagreements regarding patient priorities	Training with national experts and collaborative learning helped clinicians develop strategies to address uncertainty and trade-offs in individuals with MCCs. Patient scenarios and scripts are used to identify strategies to improve patient-provider and provider-priorities communication

PCP = primary care practitioner; EHR = electronic health record; MCCs = multiple chronic conditions.