1063 — Continuing the Conversation: An Ongoing Follow-up of Personalized Health Plans

Luger TM, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; eHealth QUERI; Bokhour BG, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; Bolton RE, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; Ruben M, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; Hogan TP, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; eHealth QUERI; Solomon J, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; Barker A, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research; Fix G, Center for Evaluating Patient Centered Care in VA; Center for Healthcare Organization and Implementation Research;

Objectives:
Personalized health planning (PHP) is a process through which Veterans and clinical teams partner to identify health goals based upon Veterans' priorities. VHA recognizes implementing PHP as a transformational activity in the Blueprint for Excellence, and considers PHP to be a "living document" meant to be revisited at least annually. Ongoing Veteran-team follow-up conversations are imperative to support Veterans to achieve health goals and facilitate care continuity. We aimed to examine if and how clinical teams incorporate follow-up conversations with Veterans after a PHP is established.

Methods:
We conducted semi-structured interviews with 10 facility leads, identified by the Office of Patient Centered Care, who were implementing PHP within their respective programs (e.g., PACT, health coaching). Interview transcripts were analyzed using rapid content analysis, guided by the study goals, to identify any site processes for follow-up conversations.

Results:
We found variation in the extent to which follow-up conversations were incorporated, in terms of 1) time between baseline and follow-up; 2) frequency of follow-up; 3) team members responsible and 4) reminder systems. The period of time between baseline PHP completion and follow-up ranged from one week to six months. Practices ranged from no indication of a definitive process to iterative sessions in which the PHP was revisited. The team members responsible for follow-up included nurses, primary care physicians, health coaches, and peer support specialists. Some sites attempted to automate the process by designing CPRS flags or templates to alert providers of a completed PHP. In some contexts (e.g., health coaching sessions, pain clinic visits), the PHP was revisited during regularly scheduled sessions.

Implications:
While there is variation in how sites engage in PHP with Veterans, the consistency of follow-up conversations remains unclear. Sites have focused on processes for targeted implementation of the PHP, but have yet to incorporate long-term plans for follow-up conversations to ensure that PHP remains a "living document."

Impacts:
Initial PHP is only effective if these plans have a role throughout the course of clinical care of our Veterans. Establishing PHP should include a clear plan for ongoing follow-up of Veterans health goals to monitor progress and priorities.