PATIENT-CENTERED CARE CLUSTER – PROJECT 13-05161.PSU
A Person-Centered Approach for Individuals with MCCs
Currently 26% of US adults have multiple chronic conditions (MCCs). The prevalence increases to 68% for individuals 65 and older. MCCs are managed by a combination of self-care practices and community-based services. The majority of health systems across the U.S. are facing financial strains due to ever-increasing costs related to MCCs. Since the Centers for Medicare & Medicaid Services are now penalizing hospitals for readmissions there is a need to better understand the impact of personal preferences and what contextual factors shape preferences. Preference congruence has the potential to move beyond a quality indicator. Lack of preference congruence may also serve as an easily assessed indicator of patients at risk for non-adherence resulting in readmissions. Assigning interventions to the right person at the right time in the right context is essential to improve resource allocation, decision making, and care coordination.
How is this different from related research?
Person-centered care models suggest that aligning care with personal preferences may result in improved decision making, care coordination, and greater motivation to adhere (a key part of self-care) to care goals. However, relevant contextual factors that leverage personal preferences in community-based individuals with MCCs have not been identified. This research will explore the interface of individuals and organizational context in shaping preferences to understand the impact of person, provider, and environmental level factors on shaping preferences and preference congruence.
- Improve resource allocation, decision-making, and care coordination and provide actionable, cost-effective solutions
- Construct a multilevel logic model of contextual factors and interface with preferences
- Design a community, informed, testable model of the human-context-preference interface