Roadmap Overview


Skills building and education

  • Incorporate communications skills development training into educational curricula for physicians and all members of the healthcare team that provides essential scaffolding for care goals and shared decision-making discussions .
  • Develop education and clinical practice models and materials for patient-based care, including core questions and decision aids for both professionals and patients. These should include both standardized questions and questions customized to the specific disease or condition and utilize innovative digital platforms when possible.
  • Require communications skills training and proficiency in p
  • Educate the public about the value of person-centered care through media outreach programs
  • Educate advocates about specific issues and skills related to person-centered care and communications with the healthcare team



Preparing for Person-Centered Care

  • Provide every patient diagnosed with a serious or chronic illness with information and assessment materials prior to the first appointment, including:
    • Basic information on the condition
    • Core questions to assess areas of concern, treatment goals, life issues that will impact decision making and basic attitudes and needs related to the shared decision-making process. This can be done digitally.
    • Basic information on self-advocacy and how best to communicate with the healthcare team on issues related to serious illness and quality of life
  • Provide the healthcare team with the results of the assessment process prior to the appointment
  • Add sections to patient portals that address key decision-making points, quality of life, patient preference and include feedback from both patients and providers



The Initial Appointment

  • Allow sufficient time in the first appointments to have a discussion on treatment options and the shared decision-making process
  • Introduce members of the healthcare team who will be involved in patient care and explain their roles
  • Identify members of the patient’s support and caregiving team
  • Ask core questions, based on the pre-appointment assessment, about what is important to the patient in making key treatment choices
  • Assess needs related to social, emotional and financial aspects of treatment as well as symptom management.
  • Provide a summary of decisions made to the patient that forms the basis for an ongoing personalized care plan. Document these decisions on the patient portal when possible.
  • Provide patients and caregivers with an opportunity to evaluate the process and outcomes of the appointment. This can be done digitally with a few standardized questions.



The Changing Landscape of Chronic or Serious Illness

  • Identify key decision-making points for specific conditions and individual patients.
  • Build relationships that allow providers to know their patients and understand their goals and values. While physicians need to play a central role in this process, other providers, including nurse practitioners, nurses and social workers are critical to establishing and nurturing these relationships with patients and caregivers.
  • Reassess patient goals and preferences at each key decision point using standardized core questions as well as discussion personalized to the individual patient. Document outcomes using standardized platforms.
  • Review and update the personalized care plan at each critical step or decision point.
  • Provide patients with ongoing opportunities to assess their experience and improve communications with their healthcare team. This can be done through short digital assessments, patient portals, navigators and when indicated, discussions with providers.
  • Develop feedback loops and triggers to alert healthcare providers to issues that require intervention or additional discussion.



Changing Practice and Policy

  • Develop and utilize standardized measures for assessing both the process and outcomes of person-centered care and shared decision making
  • Identify and share best practices and models for person-centered care
  • Use quantitative and qualitative data to continuously improve decision making tools, skills training and assessment of the person-centered shared decision-making process
  • Use data from person-centered care to drive policy and payment reform and improve education of healthcare providers