Person-Centered Care Planning for People With Multiple Chronic Conditions: An Environmental Scan of Models and Approaches.

Introduction: Person-centered care planning (PCCP) involves active collaboration between people seeking care, clinical teams, and others to co-create longitudinal treatment plans. It is a crucial part of care for people with multiple chronic conditions (MCCs) and other complex needs. Despite the widespread acceptance of the concept, the use of PCCP in the US is variable. Many effective models of PCCP exist but uptake has been limited. Objective: We sought to identify and assess current models and approaches for PCCP by performing a multi-component environmental scan. Methods: We conducted targeted literature reviews based on streamlined systematic review methods and qualitative interviews with key informants, identified for their relevant expertise and frontline knowledge of PCCP models. Results: In all, 966 abstracts and 187 full articles met review criteria. We identified 40 models with elements fitting into 7 categories of how they differed from usual care (adding People/Roles, innovative Payment/Incentives, novel Technology, decision support Tools, Services, Functions, and Changing Focus). Most were multi-component models with evidence of effectiveness in outcomes that address the quintuple aim. Barriers to adoption and integration across sectors were primarily lack of time and appropriate payment mechanisms. A small set of measures for PCCP was identified that focused primarily on patient experience and goal setting. Similarly, a small number of PCCP models connected with social services organizations to address health-related social needs and highlighted challenges with data sharing and payment as well as growing collaborations in community care hubs to address social needs. KI interviews echoed and deepened our understanding of these findings by contextualizing experiences with barriers and factors facilitating the delivery of PCCP. Discussion: PCCP is a key aspect of high-quality care for people with MCCs; uptake is limited with barriers related to time and resources. Facilitators include alignment with healthcare system objectives and practices, and ready-to-deploy resources that enable coordinated PCCP care across providers. To promote greater adoption of PCCP concerted efforts are needed to share implementation details, success stories, and build the case for PCCP with patients, their families, and healthcare system leaders.