Patient Goals Get Top Priority in Novel Approach to Caring for Older Adults

Cleveland Clinic’s Center for Geriatric Medicine has become the first exclusively primary care site to test a patient priorities-aligned decision-making approach to care for geriatric patients with multiple chronic conditions. The study is funded by a grant from the Donaghue Foundation to Mary Tinetti, MD, Chief of Geriatrics at Yale School of Medicine, and Ardeshir Hashmi, MD, Section Chief of the Center for Geriatric Medicine at Cleveland Clinic.

“Patient Priorities Care, or PPC, is based on the idea that older adults should set the priorities for their care, not guidelines, which are based on evidence that excludes older patients with chronic comorbidities and may not be relevant to their care,” says Dr. Hashmi. “For instance, if I have a patient with diabetes, guidelines say their A1C should be below a certain number. But if getting them to that number increases hypoglycemia and their associated risk of falling, is that really a good goal?”

Furthermore, he adds, clinicians are held accountable for (and paid based on) the achievement of quality outcome metrics that may be discordant with the goals and care preferences of patients with multiple chronic conditions. This can sometimes lead to decisions that are not based on what matters most to patients and thus to unwanted care and unnecessary healthcare spending. PPC has been shown to improve patient satisfaction and outcomes and reduce healthcare costs in prior studies.

Personal goals vs. guidelines

PPC bases the management of a patient’s conditions on their personal priorities in discussion with their clinicians.

“Using the PPC paradigm, clinicians will ask a patient, ‘What’s the number one change you want to see as an outcome of your treatment?’ and start the discussion there,” says Dr. Hashmi. “Then, clinicians are able to identify treatments that bring them closer to their goals. We collaborate with the entire healthcare team to make that happen.”

Once the patient has defined their goals, a clinician reviews treatment options with them and helps decide on the approach most likely to fit their life and care preferences. They trial the treatment or lifestyle modification for three months and then re-evaluate the patient’s progress.

“Success isn’t based on a number in a guidelines document,” says Dr. Hashmi. “It’s based on if the patient is closer to their goal. So, if a patient’s main priority is being able to decrease their shortness of breath to a point where they can walk their grandchildren to school, we would be looking at how close they are to achieving that goal, not just at numbers on blood tests or imaging.”

Expanding a proven approach

Dr. Tinetti and colleagues established the feasibility of the approach in two landmark studies in the Journal of the American Geriatrics Society in 2018. A 2019 study published in JAMA Internal Medicinedemonstrated a reduction in treatment burden and unwanted healthcare in 366 older adults with multiple chronic conditions treated by primary care and cardiology with a PPC approach. PPC patients were less likely to have self-management tasks assigned (57.5% vs. 62.1%; adjusted odds ratio [AOR], 0.59; 95% CI, 0.41-0.84) and diagnostic tests ordered (80.8% vs. 86.4%; AOR, 0.22; 95% CI, 0.12-0.40), and more likely to have medications stopped (52.0% vs. 33.8%, AOR, 2.05; 95% CI, 1.43-2.95).

“Cleveland Clinic is playing a critical role in demonstrating how this approach will work in a primary care setting in a large academic health center,” says Dr. Hashmi.

Researchers will enroll 250 patients within the Cleveland Clinic Shared Savings Accountable Care Organization (ACO), randomized to either PPC at Cleveland Clinic Lakewood Family Health Center or usual care at Cleveland Clinic Brunswick Family Health Center.

“PPC national faculty trained us on how to align decision-making with patient priorities,” says James Hekman, MD, Medical Director at Cleveland Clinic Lakewood. “Care for our geriatric patients now involves setting plans for patients through the lens of what they value most in terms of quality of life.”

Researchers will compare patient and provider-reported outcomes and healthcare costs and utilizations between the two study sites.

“If we can show value of PPC at this initial site, we can scale and implement practice change strategies,” says Dr. Hashmi. “The ultimate objective is to foster policy changes at the national level on our quality metrics, performance measures and payment models in the ACO, and we are excited to play a critical role in achieving that.”

Benefit to clinicians

The PPC approach also benefits clinicians, who are relieved of the pressure to achieve outcomes that match guidelines but are not in line with patient goals. Patient satisfaction scores are higher because clinicians center the conversation on the patient’s main goal and discuss treatments in terms of progress toward that goal.

“Every healthcare leader is working toward reducing unnecessary and unwanted care, reducing clinician burnout and improving quality,” says Dr. Hashmi. “PPC accomplishes all three of those objectives by putting patients in charge of establishing their goals, providing focus and purpose for clinicians, and basing quality metrics not on unrealistic, unfeasible targets but on patient priorities.”