RT Journal Article
SR Electronic
T1 Patients’ Progress and Confidence Addressing Root Causes of Poor Health in Primary Care
JF The Annals of Family Medicine
JO Ann Fam Med
FD American Academy of Family Physicians
SP 4355
DO 10.1370/afm.21.s1.4355
VO 21
IS Supplement 1
A1 Regan, Beck
A1 Mahajan, Nihar
A1 Sabo, Roy
A1 Kashiri, Paulette Lail
A1 Hinesley, Jennifer
A1 O'Loughlin, Kristen
A1 Webel, Benjamin
A1 Krist, Alex
A1 Richards, Alicia
YR 2023
UL http://www.annfammed.org/content/21/Supplement_1/4355.abstract
AB 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.