Patient-centered plan-of-care tool for improving clinical outcomes

Nicole Rocco, Katherine Scher, Barbara Basberg, Swaytha Yalamanchi, Kimberly Baker-Genaw

Research output: Contribution to journalArticlepeer-review

14 Scopus citations


Purpose: In developing our Patient-Centered Team Care (PCTC) program, we designed a Plan-of-Care (POC) tool to facilitate the physician-patient discussion for setting health goals. This study aimed to determine the effectiveness of the POC tool in improving clinical outcomes. Methods: We compared baseline and 6-month or greater follow-up values for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SP), diastolic blood pressure (DP), and weight for PCTC patients (intervention group) and non-PCTC patients (control group). For the intervention group, we also compared POC tool completeness scores (1, low and 8, high). Results: Of 1366 patients, 1110 (593 intervention, 517 control) had baseline and follow-up clinical measures for analysis. After adjusting for demographics, significant effects occurred in the intervention group for HbA1c (P = .0067), LDL (P = .012), and DP (P = .091). For completeness of POC, a significant association occurred between more fully completed forms (scores, 5-8) and change in HbA1c (P < .001) and SP (P = .011). Conclusion: Patients receiving a POC showed significant improvement in 3 of 5 clinical outcomes compared with those without the tool, and those with more fully completed forms had significant improvement in 2 of 5 clinical outcomes compared with those with partially completed forms.

Original languageEnglish (US)
Pages (from-to)89-97
Number of pages9
JournalQuality management in health care
Issue number2
StatePublished - Apr 1 2011


  • Chronic disease management
  • health tools
  • medical home
  • outcomes
  • patient-centered care

ASJC Scopus subject areas

  • Leadership and Management
  • Health(social science)
  • Health Policy
  • Care Planning


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