Patient-centered plan-of-care tool for improving clinical outcomes

Abstract

Purpose: In developing our Patient-Centered Team Care (PCTC) program, we designed a Plan-of-Care (POC) tool to facilitate the physician-patient discussion for setting health goals. This study aimed to determine the effectiveness of the POC tool in improving clinical outcomes.

Methods: We compared baseline and 6-month or greater follow-up values for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SP), diastolic blood pressure (DP), and weight for PCTC patients (intervention group) and non-PCTC patients (control group). For the intervention group, we also compared POC tool completeness scores (1, low and 8, high).

Results: Of 1366 patients, 1110 (593 intervention, 517 control) had baseline and follow-up clinical measures for analysis. After adjusting for demographics, significant effects occurred in the intervention group for HbA1c (P = .0067), LDL (P = .012), and DP (P = .091). For completeness of POC, a significant association occurred between more fully completed forms (scores, 5-8) and change in HbA1c (P < .001) and SP (P = .011).

Conclusion: Patients receiving a POC showed significant improvement in 3 of 5 clinical outcomes compared with those without the tool, and those with more fully completed forms had significant improvement in 2 of 5 clinical outcomes compared with those with partially completed forms.