Patients’ Progress and Confidence Addressing Root Causes of Poor Health in Primary Care

Context: Patients with multiple chronic conditions (MCC) may have unmet behavioral, mental, and social needs which can be difficult to address in primary care. Care planning provides a framework for patients to be screened, collaborate on a care plan, and access a patient navigator who can support them achieving their personal health goals.

Objective: To compare patients’ progress and confidence in addressing personal care plans for different topics.

Study Design and Analysis: Clinician level randomized control trial and descriptive analyses.

Dataset: My Own Health Report (MOHR) study and navigator field notes.

Population Studied: As part of a randomized controlled trial (RCT) to evaluate a feasible approach to patient care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) in the Greater Richmond metro and the Northern Virginia areas participated in a care planning intervention. 91 patients in the intervention arm received support from a patient navigator for making and working on a goal. We focused on patients with uncontrolled chronic conditions that have complex needs.

Intervention/Instrument: Community-clinical linkage support and navigator field notes in My Own Health Report (MOHR).

Outcome Measures: We determined confidence and progress ratings (ranked by patients on 1-10 point scale), health risk assessment responses, and care plan topics selected by patients.

Results: Patients feel more confident addressing nutrition than weight loss (mean = 8.07 vs 6.31, p=0.0031). Patients tended to report better prior progress on nutrition care plans (mean = 3.80) than physical activity (mean =2.95, p=0.0024) and weight loss (mean=2.93, p=0.004).

Conclusions: Helping patients create care plans on topics they feel most comfortable addressing may better address root causes of poor health associated with chronic conditions. Connecting them with a patient navigator for the short-term may have long-term benefits for patients and care teams.