Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions

The US has a growing population of people living with multiple chronic conditions (MCC), yet the health system is ill designed to meet their needs. Person-centered care planning (PCCP) is an approach to provide comprehensive care that is responsive to the individual to improve health outcomes and increase value. To examine strategies used to provide PCCP for people living with or at risk for MCC, as well as facilitators and barriers to implementation. This qualitative study uses thematic analysis of responses from a Request for Information (RFI) published in the Federal Register soliciting input on PCCP, posted by the Agency for Healthcare Research and Quality (AHRQ) in 2022. The RFI was available for public comment from September 16, 2022, to November 15, 2022. Responses were analyzed between January 2023 and February 2024. Respondents were individuals and organizations who identify as, provide care for, or seek to improve care for individuals living with or at risk for MCC. Some responses represent multiple individuals. Qualitative themes and subthemes of the RFI responses, developed using thematic analysis through inductive and deductive coding of the open-text responses. There were a total of 58 respondents, including clinicians, researchers, patients, caregivers, and representatives from health care payer, practitioner, health system, advocacy, professional, and supporting nonprofit and industry organizations. Researchers identified 9 themes: (1) suboptimal quality of care; (2) person-centered, goal-concordant care; (3) multidisciplinary team-based care and care coordination; (4) prevention across the life course; (5) digital health solutions; (6) workflow; (7) education and self-management support; (8) payment; and (9) achieving community, health system, and payer goals. In this qualitative study of PCCP for people living with or at risk for MCC, challenges to widescale adoption of PCCP were identified along with strategies to address these challenges, including the alignment of payment, policy support, culture change, adoption of meaningful measures, and the need for evidence on strategies to scale and spread PCCP. Insights gained from this analysis can inform research priorities and implementation efforts to advance PCCP as an integral component of routine care.