[Federal Register Volume 87, Number 179 (Friday, September 16, 2022)]
[Notices]
[Pages 56950-56953]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[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: [email protected].

FOR FURTHER INFORMATION CONTACT: Poonam Pardasaney, ScD, DPT, MS, Staff 
Fellow, Phone: (301) 427-1121; Email: [email protected].

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:
     Prioritize care that maximizes benefits and minimizes 
harms.
     Incorporate and prioritize competing demands and people's 
preferences (e.g., morbidity, mortality, burden of care, quality of 
life).
     Identify roles and tasks among care team members, 
including the person with MCC.
     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.
     Elicit and reflect choices and values of people at risk 
for or living with MCC in the context of their lives.
     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.
     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.
     Document specific goals of both people at risk for or 
living with MCC and their clinicians and health care team and reconcile 
when necessary.
     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.
     Is supported by evidence-based clinical guidelines that 
optimize care for coexisting conditions.
     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: https://ecareplan.ahrq.gov/.
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Who should respond?

    AHRQ seeks information from:
     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).
     Researchers and implementers developing interventions to 
implement person-centered care planning in practice.
     Clinical decision support developers who develop tools for 
comprehensive, longitudinal person-centered care planning.
     Quality and other measure developers (e.g., metrics, 
indicators) of person-centered care planning, including process, 
implementation, and outcomes.
     Patient advocacy groups and organizations.
     Clinical professional societies.
     Payers.
     Healthcare delivery organizations.
     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.
     Vendors who develop health IT solutions that facilitate 
person-centered care planning, including traditional EHR systems, care 
planning platforms, consumer apps, and other products.
     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.
     Device developers who incorporate comprehensive 
longitudinal person-centered care planning into device software.
     People at risk for or living with MCC, their families and 
caregivers.
     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.
     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:
     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?
     What key components are necessary to fully deliver on the 
promise of person-centered care planning?
     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?
     Which organizations are successfully engaged in person-
centered care planning for people at risk for or living with MCC?
     Who are the thought leaders in this area and/or where 
would leaders go to seek information about how to begin this work?
     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?
     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?
     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?
     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)?
     What kinds of information, tools, resources, or support 
are most needed to address barriers and challenges to implementation?
     Which payment models might enable and sustain person-
centered care planning?
     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?
     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.)?
     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?
     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?
     Are there or should there be competency requirements for 
people engaged in facilitating person-centered planning processes, and 
what should those entail?
     What are suggested methods for recruiting and retaining 
the workforce to staff such programs?
     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?
     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?
     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?
     What policy levers should HHS use to further advance the 
adoption of standards-based e-care plans?
     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?

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     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?
     What are promising approaches for systematically 
identifying and addressing social determinants of health?
     Are there any programmatic adaptations that would address 
the cultural and linguistic considerations when working with minority 
populations?
     How can equity be ensured in person-centered care 
planning?
     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