Patient Priorities Care aligns healthcare decision-making and care by all clinicians with patients' own health priorities. Patient Priorities Care involves not only the health outcome goals that patients want to achieve, but also their preferences for healthcare. This approach is about aligning what outcomes patients want from their healthcare with what they are willing and able to do to achieve these outcomes. The approach begins with a member of the healthcare team helping patients identify their health outcome goals and their care preferences and preparing them to interact with their clinicians around these goals and preferences. The goals and preferences are transmitted to the patient's clinicians who use them in decision-making and communication with the patient and other clinicians.

Many older adults with Multiple Chronic Conditions receive conflicting recommendations and care that may be fragmented across clinicians. Older adults vary in what's most important when faced with tradeoffs and vary in the health-related activities they are willing and able to complete to achieve their desired outcomes. A potential solution to these problems is to move from decision-making predicated solely on disease-guidelines to decision-making based on achieving each patient's own specific health outcome goals (e.g., relief of symptoms sufficient to allow specific functional activity) within the context of what they are willing and able to do (i.e. care preferences) to achieve these outcomes.

The primary aims of the Patient Priorities Care (PPC) pilot is to assess the feasibility of aligning primary and specialty care to focus on the health priorities (i.e. specific and actionable outcome goals and care preferences) of older adults with multiple chronic conditions (MCC)

Inclusion Criteria:

• Age >65 years

• Member of Pro-Health Practice for >=3 years

• Determined to be an appropriate candidate evidenced by ANY of the following:

  • Multiple Chronic Conditions (presence of >3 active health problems)
  • >10 medications
  • ≥ 1 hospitalization over the past year
  • ≥ 2 emergency department visits over the past year
  • Seen by >2 specialists (excluding GYN and eye) over the past year

Exclusion Criteria:

• End stage renal disease
• Unable to consent (e.g. dementia)
• In hospice or meeting hospice criteria
• Nursing home resident
• Not English speaking

Interviewer and chart abstractor is blinded to the nature of the intervention and to the group assignment.