Person-Centered Care Fosters Shared Decision Making
By Jaimie Lazare
The traditional health care model typically doesn't involve patients in decisions about their health care. Person-centered care, however, places patients' preferences and goals at the forefront of decision making.
In a 2001 report, the Institute of Medicine identified patient-centered care as one of the six pillars in health care and underscored the patient's role as an integral part of the decision-making process.1 There's also been a movement toward replacing the term "patient-centered care" with "person-centered care," which embodies the entire individual's needs and preferences. Terms such as "person-directed care" and "person-focused care" have been used interchangeably with person-centered care, although differences in their meanings have been suggested.2
To set person-centered care (PCC) apart, The SCAN Foundation gathered a team of interdisciplinary experts from the American Geriatrics Society (AGS) and the Keck School of Medicine of the University of Southern California to spearhead a research project to develop a standard agreed-upon definition and core elements of PCC for older adults with chronic conditions and functional limitations.
What Is PCC?
"If you have measurable parameters, which lead to measurable outcomes, it helps us do a better job. We know what to focus on, we know when we're missing the boat, and we know when to make course corrections," she says.
The panel experts held many discussions about whether to use the term "patient-centered" or "person-centered," and Mosqueda credits the SCAN Foundation with pushing for the care to be called person-centered. In addition, the panel identified 15 definitions of PCC or terms that were similar to it. The panel's final definition is as follows: "person-centered care means that individuals' values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers."3 The panel also developed the following eight core elements to support the definition:
• an individualized, goal-oriented care plan based on the person's preferences;
Implementing the Person-Care Approach
Implementing PCC in clinical practice requires understanding what it means. Counsell says it's important to review the definition and thoughtfully reflect on how it may differ from the way in which physicians currently practice medicine. "One of the primary goals of the consensus panel was to address what is meant by person-centered care and how to help support physicians and other health care professionals," he says.
Mosqueda notes that while physicians can certainly take leadership roles, all health care professionals need to know what PCC means and how to apply it when caring for their older adult patients. "As geriatricians, we can be role models and serve as patient advocates," she says. "As an advocate for patients, if we think things are going off the rails a little with one of the specialists, then as geriatricians, we're there to kind of get things back in the right balance."
Mosqueda recounts an office visit with an Ethiopian woman diagnosed with a form of brain cancer and her family. The woman had multiple medical problems, but the conversation was focused on the side effects of the Coumadin she had been taking. By taking a person-centered approach, Mosqueda says she placed her patient and the patient's family at the center of making decisions based on not only the medical issues but also within the context of the patient's values and philosophy.
After a few minutes of discussion, the patient expressed her satisfaction because both she and her family participated in the decision-making process. "Now it's not going to be a decision that they worry about or question because they were appropriately involved in making the decision," she says.
Mosqueda says that it's essential to think of individuals in the context of their lives and what's important to them, to develop a medical or health care plan that's aligned with those values, and to review patients' goals on an ongoing basis.
"Ongoing information sharing and communication among the person, family, and caregivers is another distinguishing feature of person-centered care because communication doesn't end with that initial expression of values and preferences by the person," Counsell says. "What's important to that person is an ongoing conversation that's continually aligned with that person's health care goals."
In addition to the development by the panel of a standard agreed-upon definition of PCC, The Centers for Medicare & Medicaid Services (CMS) has also implemented measures to integrate PCC into health care. Through recommendations made by AGS and 65 partner organizations, CMS now recognizes voluntary advance care planning (ACP) as a reimbursable Medicare benefit. Two new codes allow clinicians who treat older adults to track ACP services. ACP allows physicians to be paid for the time spent in speaking to patients about their specific health goals and preferences, Counsell says.
There are two ACP codes: 99497 is a current procedural terminology (CPT) code for the first 30 minutes spent discussing goals and preferences and an advance directive, "with or without completing relevant legal forms," and 99498 is an add-on code for each additional 30-minute ACP discussion. "These new codes underscore the importance of promoting ACP to Medicare beneficiaries and tangibly provide a way that physicians can build this into their practice and receive reimbursement," Counsell says.
In 2015, CMS also provided a separate payment under the code 99490 for the time clinical staff may spend managing chronic care management services. Counsell says that if a nurse or social worker is making phone calls to help coordinate care or to provide assistance to caregivers, these services can be billed. He adds, "It's a bit complicated to bill for it, so the uptake hasn't been really good as yet, but reimbursement by Medicare for these type services will help to drive change and address some of the barriers that have been articulated by physicians in doing this kind of work."
Addressing Potential Barriers to PCC
Counsell says, "To break through some of the barriers of addressing person-centered care, clinicians need to collaborate with community-based organizations." Often there are community resources physicians don't tap into to alleviate some of the pressures involved in meeting a person's needs. "So integrating your office with some of the social services can also be helpful," he says.
"Person-centered care is all about what's important to the person's quality of life. Geriatricians realize that it's not all about the doctor and the medical treatment; it's the whole team that's involved in optimizing someone's quality of life and independence and that involves nurses, social workers, dietitians, pharmacists, and therapists," Counsell says.
Counsell says it's necessary to approach PCC on different levels. First is the individual level: Physicians can try to improve on one or two PCC elements within the practice. Second is the health care level: Physicians can push their health care systems forward in specific directions because there's now a document to reference and note the objectives to which they should be aspiring. Third is the patient level: Physicians can begin to educate patients; as clinicians begin to behave differently and include patients, this approach will likely be new for them as well.
"The person-centered care elements provide a blueprint that can be used for strategic planning because it's quite practical and specific, and it allows flexibility in your individual site where you're providing care to see how to apply it," Mosqueda says. "If you focus on what's important to the individual, that's going to engage them more in the self-management of their conditions. So if you align health care goals with life goals, that's a win-win."
— Jaimie Lazare is a freelance writer based in Brooklyn, New York.
2. Kogan AC, Wilber K, Mosqueda L. Person-centered care for older adults with chronic conditions and functional impairment: a systematic literature review. J Am Geriatr Soc. 2016;64(1):e1-7.
3. American Geriatrics Society Expert Panel on Person-Centered Care. Person-centered care: a definition and essential elements. J Am Geriatr Soc. 2016;64(1):15-18.