Effect of Patient Priorities Care Implementation in Older Veterans With Multiple Chronic Conditions

Effect of Patient Priorities Care Implementation in Older Veterans With Multiple Chronic Conditions

The investigators will conduct a randomized control trial enrolling 420 older Veterans with multiple chronic conditions receiving primary care at the Michael E. DeBakey VA Medical Center and VA Connecticut Medical Center to determine if Patient Priorities Care reduces treatment burden, increases priorities-aligned home and community services, and sets shared health outcome goals compared with usual care. The investigators will randomize at the patient level rather than clinic or clinician level to evaluate the effect of identifying patient priorities on clinician decision making and alignment of care with identified priorities.

Inclusion Criteria:

• 2 encounters in prior 18 months
• 3 active health problems on active problem list or prescribed 10 medications

Exclusion Criteria:

• nursing home resident

• end stage renal disease on dialysis

• active serious mental illness (psychosis, schizophrenia, etc)

• active substance use disorder

• complete hearing loss

• dementia

• Non-English speaker (translator required)

• 4 or more no-show appointments in the last 6 months

• the investigators will present a list of eligible patients to PCPs prior to chart review to identify patients who the PCP:

  • a) believes cannot participate independently or provide informed consent due to cognitive impairment
  • b) "would not be surprised if the patient passed away within the next 12 months?"