UMMS Affiliation

Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Health Services Administration | Health Services Research | Military and Veterans Studies | Primary Care


BACKGROUND: Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited.

OBJECTIVE: We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice.

DESIGN: Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding.

PARTICIPANTS: Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers.

KEY RESULTS: Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning.

CONCLUSIONS: Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.


Veterans, patient-centered care, primary care, qualitative research

Rights and Permissions

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

DOI of Published Version



J Gen Intern Med. 2019 Oct 24. doi: 10.1007/s11606-019-05418-4. [Epub ahead of print] Link to article on publisher's site

Journal/Book/Conference Title

Journal of general internal medicine

PubMed ID


Related Resources

Link to Article in PubMed