Moving Person-Centered Care Planning From Theory Into Practice: Patient Perspectives.

Introduction: Persons with multiple chronic conditions often receive care from a complicated network of multiple providers across multiple health systems unique to their conditions, needs, available resources, and insurance. Patients must navigate this healthcare system, which is a difficult and complicated process with just one provider or system, let alone multiple. Developing new solutions to overcome the systemic challenges within healthcare systems to provide high-quality, comprehensive, person-centered care for persons living with, or at risk for, multiple chronic conditions is critical. Person-centered care is needed, not only because it is the right and just approach to supporting patients, but because of the profound implications of the increasing prevalence of multiple chronic conditions on healthcare costs, caregiver burden, workforce productivity, and the broader social fabric. In this commentary, we present patient perspectives on a project that brought together diverse groups to identify potential solutions to challenges in implementation of person-centered care. Methods: Patients, families, and family caregivers are essential to the design and implementation of person-centered care planning for people with multiple chronic conditions. The Agency for Healthcare Research and Quality (AHRQ) funded a project aimed at compiling best practices and discussing barriers. The project used a learning system approach to engage policy experts, clinicians, researchers, and persons with multiple chronic conditions, their families, and family caregivers. Four main activities included a technical expert panel, an environmental scan, a partner roundtable, and a learning collaborative. An in-person/hybrid summit held in March 2025 summarized activities and provided a forum for presentations to share activities of the project and conduct small group discussions on select topics. Results/Framework: We present patient narratives to complement content provided by the partner roundtables and other AHRQ-funded activities that provided foundational knowledge and diverse perspectives to promote person-centered care planning as standard practice for persons with multiple chronic conditions. Although many challenges to implementation of person-centered care were identified and discussed, learning from successful models and customization of models using components as appropriate may help overcome barriers. In particular, the need for culture change, use of meaningful measures, scalability, and other concepts must be addressed. Alignment of payment structures and policy support will be essential to ensuring that person-centered care can be advanced as an integral component of routine care. Conclusion/Next Steps: Multiple challenges to adoption of person-centered care planning have been identified. Future work by multidisciplinary teams (that must include patients, caregivers, policymakers, and clinicians) is needed to develop evidence-based feasible solutions to overcome these barriers in ways that respect the values and preferences of patients, families, and caregivers.