Notice2022-20027
Request for Information on Person-Centered Care Planning for Multiple Chronic Conditions (MCC)
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
September 16, 2022
Issuing agencies
Health and Human Services DepartmentAgency for Healthcare Research and Quality
Abstract
The Agency for Healthcare Research and Quality (AHRQ) seeks public comment about comprehensive, longitudinal, person-centered care planning for people with Multiple Chronic Conditions (MCC). Specifically, the RFI seeks comment on the current state of comprehensive, longitudinal, person-centered care planning for people at risk for or living with MCC across settings of care (e.g., health systems, primary care, home, and other ambulatory practices), including existing models of person-centered care planning, their current scale, and barriers and facilitators to implementation. In addition, the RFI seeks comments about innovative models of care, approaches, promising strategies and solutions in order for clinicians and practices to routinely engage in comprehensive, longitudinal, person-centered care planning to improve the care of people at risk for or living with MCC. This request for information will inform AHRQ's work in improving care for people at risk for or living with MCC.
Full Text
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<title>Federal Register, Volume 87 Issue 179 (Friday, September 16, 2022)</title>
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[Federal Register Volume 87, Number 179 (Friday, September 16, 2022)]
[Notices]
[Pages 56950-56953]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-20027]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
Request for Information on Person-Centered Care Planning for
Multiple Chronic Conditions (MCC)
AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS.
ACTION: Notice of request for information.
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SUMMARY: The Agency for Healthcare Research and Quality (AHRQ) seeks
public comment about comprehensive, longitudinal, person-centered care
planning for people with Multiple Chronic Conditions (MCC).
Specifically, the RFI seeks comment on the current state of
comprehensive, longitudinal, person-centered care planning for people
at risk for or living with MCC across settings of care (e.g., health
systems, primary care, home, and other ambulatory practices), including
[[Page 56951]]
existing models of person-centered care planning, their current scale,
and barriers and facilitators to implementation. In addition, the RFI
seeks comments about innovative models of care, approaches, promising
strategies and solutions in order for clinicians and practices to
routinely engage in comprehensive, longitudinal, person-centered care
planning to improve the care of people at risk for or living with MCC.
This request for information will inform AHRQ's work in improving care
for people at risk for or living with MCC.
DATES: Comments on this notice must be received by November 15, 2022.
AHRQ will not respond individually to responders but will consider all
comments submitted by the deadline.
ADDRESSES: Please submit all responses via email to: <a href="/cdn-cgi/l/email-protection#eaa7a9a9aa8b82989bc4828299c48d859c"><span class="__cf_email__" data-cfemail="e8a5ababa889809a99c680809bc68f879e">[email protected]</span></a>.
FOR FURTHER INFORMATION CONTACT: Poonam Pardasaney, ScD, DPT, MS, Staff
Fellow, Phone: (301) 427-1121; Email: <a href="/cdn-cgi/l/email-protection#da8ab5b5b4bbb7f48abba8bebba9bbb4bfa39abbb2a8abf4b2b2a9f4bdb5ac"><span class="__cf_email__" data-cfemail="65350a0a0b04084b350417010416040b001c25040d17144b0d0d164b020a13">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION: AHRQ is seeking public comment about
comprehensive, longitudinal, person-centered care planning for people
at risk for or living with Multiple Chronic Conditions (MCC).
Specifically, AHRQ seeks comment on the current state of comprehensive,
longitudinal, person-centered care planning for people at risk for or
living with MCC across settings of care (e.g., health systems, primary
care, home, and other ambulatory practices) including existing models
of person-centered care planning, their current scale, and barriers and
facilitators to implementation. In addition, AHRQ seeks information
about innovative models of care, approaches, and promising strategies
and solutions, in order for clinicians and practices to routinely
engage in comprehensive, longitudinal, person-centered care planning to
improve the care of people at risk for or living with MCC. Because it
may be possible to prevent or delay the onset of MCC, AHRQ is
interested in care planning for those at risk for MCC in addition to
those who have MCC. Evidence for effectiveness of strategies for
implementation and delivery of person-centered care planning, their
impact on improving health outcomes, as well as evidence on how to
adapt, scale, and spread the intervention are of interest.
For the purposes of this RFI, the following working definitions
apply:
Comprehensive, Longitudinal, Person-Centered Care Planning (also
known as shared care planning): A process of collaboration among people
at risk for or living with MCC, clinicians, and healthcare teams to
proactively discuss and record: (1) roles and tasks among care team
members, including the individual, their family and caregivers; (2)
plans for coordinating care within and across organizations and
settings; (3) strategies for supporting and empowering patients to
manage their own health; (4) plans for engaging in shared decision
making.\1\ The care plan should: include all conditions including
biomedical and behavioral health conditions; facilitate screening for
and/or diagnosing co-existing conditions that impact care management
and outcomes, as well as social risks and supports; support evidence-
based care; include an individual's goals and preferences; be dynamic
and incorporate an approach to updating, as necessary.
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\1\ Burt, J., et al., Care plans and care planning in long-term
conditions: a conceptual model. Prim Health Care Res Dev, 2014.
15(4): p. 342-54.
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Person-Centered Care Plan: A single record of care shared among
people at risk for or living with MCC and their clinicians that: (1) is
accessible to persons with MCC and their caregivers; (2) puts the
person's goals at the center of decision-making; (3) is holistic,
including somatic and behavioral health, clinical and nonclinical data,
including the social determinants of health; (4) follows the person
through both high-need episodes and periods of health improvement and
maintenance; (5) allows care team coordination.\2\
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\2\ Baker, A., et al., Making the Comprehensive Shared Care Plan
a Reality. NEJM Catalyst, 2016.
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Multiple Chronic Conditions (MCC) are defined here as the co-
occurrence of two or more chronic physical or behavioral health
conditions (including mental health and/or substance use disorders).
Some use the term multimorbidity as synonymous with MCC, while others
define MCC as including additional factors that contribute to the
burden of illness, including disease severity, functional impairments
and disabilities, syndromes such as frailty, and sometimes social
factors such as homelessness.
Importance of Care Planning for People at Risk for or Living With MCC
Comprehensive, longitudinal, person-centered care planning is
central to models of care that deliver high quality care that meet the
needs of people at risk for or living with MCC. Person-centered care
planning should be designed to achieve the following objectives:
<bullet> Prioritize care that maximizes benefits and minimizes
harms.
<bullet> Incorporate and prioritize competing demands and people's
preferences (e.g., morbidity, mortality, burden of care, quality of
life).
<bullet> Identify roles and tasks among care team members,
including the person with MCC.
<bullet> Coordinate planning, management and treatment with the
whole care network across time and setting (e.g., a multi-disciplinary
team, specialty care, community and social services, people with MCC
and caregivers) to create and maintain a single plan for each person.
<bullet> Elicit and reflect choices and values of people at risk
for or living with MCC in the context of their lives.
<bullet> Share decision making in a manner that is preferred by
people at risk for or living with MCC and caregivers, considering
individual values, preferences, cultural, and social contexts.
<bullet> Support and empower people at risk for or living with MCC
to manage their own health and initiate and sustain behavior change,
with the support of their health care team.
<bullet> Document specific goals of both people at risk for or
living with MCC and their clinicians and health care team and reconcile
when necessary.
<bullet> Continuously monitor and track progress on goals and
preferences through high-need episodes, as well as during periods of
health improvement and maintenance, with modification as necessary.
<bullet> Is supported by evidence-based clinical guidelines that
optimize care for coexisting conditions.
<bullet> Ensure equity is adequately addressed to deliver effective
person-centered care to all and actively reduce health inequities
including among Black, Indigenous, and people of color (BIPOC);
socioeconomically disadvantaged individuals; across Sexual Orientation
and Gender Identity (SOGI)); for those with low levels of health
literacy or limited English proficiency; and for persons with
disabilities.
Implementing comprehensive, longitudinal, person-centered care
planning requires fundamental changes in the way care is organized and
delivered in order to ensure: the active engagement and shared learning
of diverse stakeholders; the capacity for timely implementation of
rapidly evolving evidence; and innovative approaches to care
transformation. While person-centered care planning is practiced in
some care settings, it is not routine practice and there are
significant evidence gaps regarding the most effective approaches for
implementation, scale, and spread.
[[Page 56952]]
Additionally, the use of shared electronic care plans (e-care plans)
can facilitate coordination and communication among people at risk for
or living with MCC and their clinicians and health care teams, and
provide a shared resource for documenting goals, treatments and
supports, education and self-management, along with other patient-
generated health data to support care management.\3\
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\3\ AHRQ. eCare Plan Joint NIH/NIDDK AHRQ Project. 9/22/2021;
Available from: <a href="https://ecareplan.ahrq.gov/">https://ecareplan.ahrq.gov/</a>.
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Who should respond?
AHRQ seeks information from:
<bullet> Clinicians and other health care personnel who perform
some or all key components of comprehensive, longitudinal person-
centered care planning for people at risk for or living with MCC,
including clinicians and personnel from across all care settings
(primary care, specialty care, mental and behavioral health, post-acute
care, rehabilitative care, and home and community-based services).
<bullet> Researchers and implementers developing interventions to
implement person-centered care planning in practice.
<bullet> Clinical decision support developers who develop tools for
comprehensive, longitudinal person-centered care planning.
<bullet> Quality and other measure developers (e.g., metrics,
indicators) of person-centered care planning, including process,
implementation, and outcomes.
<bullet> Patient advocacy groups and organizations.
<bullet> Clinical professional societies.
<bullet> Payers.
<bullet> Healthcare delivery organizations.
<bullet> IT Directors who implement and manage health IT and other
systems that may support person-centered care planning by people with
MCC and their clinicians and health care teams.
<bullet> Vendors who develop health IT solutions that facilitate
person-centered care planning, including traditional EHR systems, care
planning platforms, consumer apps, and other products.
<bullet> Organizations that facilitate health information exchange
(i.e., regional or local health information exchanges, vendor-driven
networks, and others) who may support sharing of care plan information
across systems.
<bullet> Device developers who incorporate comprehensive
longitudinal person-centered care planning into device software.
<bullet> People at risk for or living with MCC, their families and
caregivers.
<bullet> Representatives from human service agencies and/or
community organizations, or people with experience in addressing the
social determinants of health and reducing disparities for people at
risk for or living with MCC.
<bullet> Higher education institutions that train clinicians and
healthcare personnel and/or train those involved in community health
and education.
Specific questions of interest to AHRQ include, but are not limited
to, the following:
<bullet> What terms, strategies, and models of care are used to
describe and deliver care planning for the whole person (not just for
individual health conditions) that records: (1) roles and tasks among
care team members, including the individual, their family and
caregivers; (2) plans for coordinating care within and across
organizations and settings; (3) strategies for supporting and
empowering patients to manage their own health; (4) plans for engaging
in shared decision making?
<bullet> What key components are necessary to fully deliver on the
promise of person-centered care planning?
<bullet> How is comprehensive, longitudinal, person-centered care
planning for people at risk for or living with MCC currently being done
in health systems, primary care, and other ambulatory practices?
<bullet> Which organizations are successfully engaged in person-
centered care planning for people at risk for or living with MCC?
<bullet> Who are the thought leaders in this area and/or where
would leaders go to seek information about how to begin this work?
<bullet> What are examples of innovative models of care,
approaches, promising strategies and solutions that could support
clinicians and practices in routinely engaging in comprehensive,
longitudinal, person-centered care planning to improve the care of
people at risk for or living with MCC?
<bullet> How are health systems, primary care, and other ambulatory
care practices using innovative approaches to implement person-centered
care planning for people at risk for or living with MCC?
<bullet> What are best practices for designing, implementing, and
evaluating person-centered care planning for people at risk for or
living with MCC? What implementation challenges are clinicians and
systems likely to face?
<bullet> What are suggested strategies for effective implementation
of person-centered care planning at multiple levels (e.g., policy,
system, practice, clinical team, people with MCC)?
<bullet> What kinds of information, tools, resources, or support
are most needed to address barriers and challenges to implementation?
<bullet> Which payment models might enable and sustain person-
centered care planning?
<bullet> What quality of care measurements (e.g., metrics,
indicators) exist or are emerging for assessing process,
implementation, and outcomes associated with person-centered care
planning?
<bullet> Which personnel or roles within systems or practice
settings would know most about person-centered care planning efforts,
challenges, and successes (e.g., IT directors, c-suite, care
coordinators, etc.)?
<bullet> Within systems/practice settings, who takes the lead, or
would be expected to take the lead, in coordinating efforts to
implement person-centered care planning?
<bullet> What credentials and/or training of the team members,
including paraprofessionals such as community health workers and/or
persons with lived experience such as peer recovery specialists are
necessary?
<bullet> Are there or should there be competency requirements for
people engaged in facilitating person-centered planning processes, and
what should those entail?
<bullet> What are suggested methods for recruiting and retaining
the workforce to staff such programs?
<bullet> What are the impacts of different models of person-
centered care planning on the experience of clinicians and other
healthcare personnel, and are increased demands posed by some models
precipitating practitioner burnout?
<bullet> How have shared electronic care plans (e-care plans) been
developed, implemented, and shared with the care team? What are best
practices for sharing e-care plans across sites and settings of care?
<bullet> What existing and emerging data standards are effectively
supporting the interoperability of e-care plans? What key standards
gaps around e-care plans should be prioritized by industry and other
stakeholders?
<bullet> What policy levers should HHS use to further advance the
adoption of standards-based e-care plans?
<bullet> How can technical approaches using Fast Healthcare
Interoperability Resources (FHIR) standards better support sharing of
e-care plans across care teams? What are major barriers to advancing
these approaches?
[[Page 56953]]
<bullet> What are best practices for using e-care plans to
facilitate communication among people at risk for or living with MCC,
their caregivers, clinicians, and health care teams, and provide a
shared resource for documenting goals, treatments and supports,
education and self-management, along with other patient-generated
health data?
<bullet> What are promising approaches for systematically
identifying and addressing social determinants of health?
<bullet> Are there any programmatic adaptations that would address
the cultural and linguistic considerations when working with minority
populations?
<bullet> How can equity be ensured in person-centered care
planning?
<bullet> What are active areas of research and gaps in knowledge?
AHRQ is interested in all of the questions listed above, but
respondents are welcome to address as many or as few as they choose and
to address additional areas of interest regarding comprehensive
longitudinal person-centered care planning not listed. It is helpful to
identify the question to which a particular answer corresponds.
This RFI is for planning purposes only and should not be construed
as a policy, solicitation for applications, or as an obligation on the
part of the Government to provide support for any ideas in response to
it. AHRQ will use the information submitted in response to this RFI at
its discretion and will not provide comments to any respondent's
submission. However, responses to this RFI may be reflected in future
solicitation(s) or policies. The information provided will be analyzed
and may appear in reports. Respondents will not be identified in any
published reports. Respondents are advised that the Government is under
no obligation to acknowledge receipt of the information received or
provide feedback to respondents with respect to any information
submitted. No proprietary, classified, confidential or sensitive
information should be included in your response. The contents of all
submissions will be made available to the public upon request.
Submitted materials must be publicly available or able to be made
public.
Dated: September 12, 2022.
Marquita Cullom,
Associate Director.
[FR Doc. 2022-20027 Filed 9-15-22; 8:45 am]
BILLING CODE 4160-90-P
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