PROJECT SUMMARY Multiple chronic conditions (MCC) affects one of four Americans, three of four in the population 65 and older, representing a growing group for which healthcare must find ways to effectively care. For this group of individuals, care planning that is based upon disease specific guidelines alone is insufficient. Tasks out of line with patient's context may lead to unsustainable self-management strategies and ultimately, non-adherence. Our research team has designed a communication tool, the ICAN Discussion Aid, to bring concepts of patient context directly into the patient-clinician encounter, where treatment plans are discussed and decided upon. Yet, additional development work is required to provide guidance for health professionals regarding how to translate this contextual information into effective care plans for patients with MCC. Our aim in this proposal is to use user-centered design to create an ICAN Implementation Toolkit that guides a wide array of health professionals, including physicians, nurses, care coordinators, social workers, community health workers, and health coaches, how to effectively translate ICAN conversations into treatment plans. The process of user-centered design follows the SPARC framework. We will See current best practices leading to treatment plans through observations of current ICAN users, Plan implementation toolkit components that help future users of ICAN create action plans, Act by testing the implementation toolkit with new users in the social network of current collaborators, Revise the toolkit based on feedback, and Communicate the toolkit's release through our website and social media platforms. The proposed study will meet a critical need for healthcare professionals caring for patients with MCC. ICAN with its supporting implementation toolkit will allow them to have conversations that draw out patients' context and goals of care and translate these conversations into effective care plans. Ultimately, these care plans should lead to conversations that are more satisfying for patients and the health professionals who care for them, care plans that allow patients to better access and use healthcare and enact self-care given their context, and ultimately better patient-important outcomes such as quality of life. While these hypotheses are outside the scope of this developmental study, the proposed work will set up implementation opportunities and future testing in this area of research.
- National Institutes of Health