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Healing Tool Series: Personalized Care Planning for Medically Complex Patients in Primary Care

Journal article about using personalized care plan to improve care for medically complex, high-need patients.

“Healing Tools” summaries are a collection of evidence-based resources to help providers and patients use integrative health approaches to improve health and wellbeing.

This tool is for: Providers

This tool was created by:Samuel T. Edwards, MD, MPH, David A. Dorr, MD, MS, and Bruce E. Landon, MD, MBA, MSc Published in JAMA


What is this tool for?

Medically complex, high-needs patients require more than routine primary care and physicians should play an enhanced role in managing their health. Personalized care planning is a formal process in which clinicians collaborate with these patients to create long-term treatment plans.

The Centers for Medicare and Medicaid (CMS) has mandated patient-centered care plans to bill for chronic care management services for Medicare patients with multiple chronic conditions. Medical home initiatives have also adopted care planning. Since chronic care management services for Medicare patients are broadly applicable, implementation of care planning is likely to increase significantly.

Personal Care Plans

A personal care plan usually consists of:

  • Problem lists
  • Measurable treatment goals
  • Symptom management plan
  • Active medications list
  • Recommended community services
  • Schedule for periodic review of the plan

While care planning could be burdensome for primary care practices and patients, this summary describes ways to address issues and do effective care planning (see also “What are the drawbacks to using this tool?” below).

While there is no standard definition of care planning, the authors identify three key components in the JAMA article (2017;318(1):25-26. doi:10.1001/jama.2017.6953):

  1. Defining and integrating patient goals
  2. Optimizing quality of chronic disease management
  3. Providing a central care record

Components of Personalized Care Planning

Defining and integrating patient goals

Instead of relying on guidelines, the clinician has an open-ended discussion with the patient to align medical care with the patient’s personal goals. Often, the patient completes a care planning tool before visits. Together, the clinician and patient develop the care plan.

Optimizing quality of chronic disease management

Care planning related to chronic disease management usually focuses on:

  • Closing gaps in care
  • Managing medications
  • Educating the patient
  • Coordinating care across multiple clinical settings

Non-medical barriers to care can also be addressed. These include:

  • Lack of transportation to appointments
  • Being unable to afford medications or healthy foods

Providing a central care record

Ideally, all clinicians caring for the patient, along with the patient, contribute to the care plan. When this happens, the care plan provides a centralized, easily accessible source for comprehensive information. Benefits include:

  • Eliminating the need to read progress notes from different clinicians to learn a patient’s full care “plan.”
  • Replacing isolated, incomplete, and poorly organized information.

How does this contribute to an integrative approach?

Combining conventional medicine, self-care, and complementary and alternative medicine can help patients achieve optimal healing and wellbeing. Involving the medically complex, high-needs patient in care planning makes self-care a key part of healthcare. Personalized care plans widen the lens of the traditional medical encounter to enable providers to better understand patients’ specific challenges within their lives and their communities.

What does the evidence say about this tool?

A 2015 Cochrane systematic review found that personalized care planning may lead to small improvements in:

  • Some indicators of physical health:
    • Better blood glucose levels
    • Lower blood pressure measurements
    • Control of asthma
  • Symptoms of depression
  • Patients’ confidence and skills to manage their health

The researchers found no effect on cholesterol, body mass index, or quality of life.

The authors concluded that:

“The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.”

The Cochrane systematic review was based on:

  • 19 randomized trials published before July 2013
  • 10,856 participants with conditions such as diabetes, mental health problems, heart failure, kidney disease and asthma

What are the drawbacks to using this tool?

If not done effectively, personalized care planning can be burdensome, adding cost and complexity without improving care or outcomes.

Issues to Be Addressed

  1. Care planning takes a significant amount of time and should be reserved for patients most likely to benefit.
    • Clear guidelines for the appropriate patient population for care planning are necessary.
    • Having two or more chronic conditions, as specified by CMS, may not be sufficient to require care planning.
  1. Practices need to determine the most appropriate personnel for care planning:
    • In large practices and patient-centered medical homes, a nurse manager may be the best person to do care planning.
    • In small or solo practices, physicians may need to do care planning.
  1. The care plan must play a central role in patient care.
    • It must be used at every visit and regularly updated.

Who created this tool?

The co-authors of this article are:

  • Samuel T. Edwards, MD, MPH:
    • Section of General Internal Medicine, Veterans Affairs (VA) Portland Health Care System
    • Division of General Internal Medicine and Geriatrics, Oregon Health & Science University
  • David A. Dorr, MD, MS:
    • Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University
  • Bruce E. Landon, MD, MBA, MSc:
    • Department of Health Care Policy, Harvard Medical School
    • Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center

The article is available:

  • For free to JAMA subscribers
  • By buying or renting the article


At Healing Works Foundation, we believe that achieving optimal health and wellbeing requires an integrative health approach—one that combines and coordinates conventional medicine, self-care, and complementary and alternative medicine.

Translating Evidence into Action

The goal of these summaries is to help providers and patients learn about and access evidence-based integrative health tools.


Healing Works Foundation is a nonprofit organization and does not profit from any of the tools featured in these summaries.

Patients: Contact your provider before starting any new health program.  Show him/her these resources.

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