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Patient Priorities Care (PPC)

CompletedNA

Sponsor: Yale University

Conditions: Multiple Chronic Conditions

Interventions: Patient Priorities Care

Patient Priorities Care aligns healthcare decision-making and care by all clinicians with patients' own health priorities. Patient Priorities Care involves not only the health outcome goals that patients want to achieve, but also their preferences for healthcare. This approach is about aligning what outcomes patients want from their healthcare with what they are willing and able to do to achieve these outcomes. The approach begins with a member of the healthcare team helping patients identify their health outcome goals and their care preferences and preparing them to interact with their clinicians around these goals and preferences. The goals and preferences are transmitted to the patient's clinicians who use them in decision-making and communication with the patient and other clinicians.

Eligibility overview

Sex: ALL

Age: 66 Years to —

Healthy volunteers: No

Study type: INTERVENTIONAL

Eligibility criteria

Inclusion Criteria:

* Age \>65 years
* Member of Pro-Health Practice for \>=3 years
* Determined to be an appropriate candidate evidenced by ANY of the following:

  * Multiple Chronic Conditions (presence of \>3 active health problems)
  * \>10 medications
  * ≥ 1 hospitalization over the past year
  * ≥ 2 emergency department visits over the past year
  * Seen by \>2 specialists (excluding GYN and eye) over the past year

Exclusion Criteria:

* End stage renal disease
* Unable to consent (e.g. dementia)
* In hospice or meeting hospice criteria
* Nursing home resident
* Not English speaking