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Personalized care planning: Take charge of your chronic illness before it takes charge of you

The Bottom Line

  • Personalized care planning involves patients and healthcare providers collaborating on the management of health conditions through conversations where management goals are set, and an action plan to achieve these goals is made.
  • In people with chronic conditions, personalized care planning can improve aspects of physical health, mental health, and the ability to self-manage conditions—generally by a small amount. 
  • This tailored and hands-on approach may provide the greatest impact when it involves: more stages from the seven-step personalized care planning processes, more intensive support from healthcare providers, and the patient’s usual healthcare provider.  

Chronic (or long-term) illness is like a game of dodge ball—it leaves you constantly ducking and sidestepping to avoid the next challenge. But what if you could take charge and manage your illness instead of letting it manage you?


Chronic diseases—such as cancer, diabetes, cardiovascular disease, respiratory diseases, and mood and anxiety disorders (1)—are growing at an alarming rate (2;3). The risk is particularly high in the aging population, with many Canadians over the age of 50 suffering from multiple chronic illnesses at once (4). Unfortunately, the more chronic conditions you have, the more likely it is that your quality of life will be poor, that you will end up in the hospital, and that you will get conflicting information from your healthcare providers (5).


Most often, the management of chronic illness is "reactive", meaning that action is taken when you are sick. But, a different way to deal with chronic illness is to be "proactive"and meet it head-on, this means placing the emphasis on nourishing your ability to manage your own condition(s) and health instead. This shift is the aim of the Chronic Care Model (6;7;8;9), which looks to empower and encourage you to be an active participant in your own health, by making you more knowledgeable about your health condition(s) and involving you in decisions around your care (6).


Personalized care planning is one strategy that follows this model. At its core, it involves you and your healthcare provider (and potentially even your caregiver) discussing the treatment and management of your condition(s), and then working together to develop appropriate management goals and an action plan for achieving them. At its most comprehensive, personalized care planning is a seven-step process that involves: patient preparation, goal setting, developing an action plan, documenting the process, coordination of the process by the healthcare provider, patient support, and monitoring of progress. Planning can lead to conversations about tests, treatments, information about self-management, education, support, or ways to change behaviours, problem solve, or manage stress (6).


Sounds great, right? But how beneficial is it?


What the research tells us

One systematic review looked at the effects of personalized care planning on physical and mental health, the ability to self-manage medical conditions, and the use of health services in people with chronic diseases—including diabetes, asthma, mental health problems, heart failure, and kidney disease. Personalized care planning was compared to instances where healthcare professionals were the sole decision makers.


So, after all was said and done, what was the takeaway?


Well, it may come as no surprise that personalized care planning was found to have several benefits for patients. In particular, the review showed that this tailored approach can result in decreases in blood sugar levels and some aspects of blood pressure in people with diabetes, improve lung function in people with asthma, reduce depression symptoms, and increase confidence and skills for disease self-management. Although these effects were often small, personalized care planning may be most beneficial when it includes more stages of the seven-step process, involves more frequent contact between patients and healthcare providers, and is used by the patient’s usual healthcare provider. Even better…negative side effects as a result of this approach were not seen (6).


For many people, chronic illness is a fact of life. But, personalized care planning can inform and empower you to better manage your health and care decisions. Maybe it’s time to talk to your healthcare provider about how you can collaborate throughout your health care journey!

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References

  1. Public Health Agency of Canada. Canadian chronic disease indicators, quick stats, 2017 edition. [Internet] 2017. [cited January 2019]. Available from  https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-37-no-8-2017/at-a-glance-2017-canadian-chronic-disease-indicators.html  
  2. Massimi A, De VC, Brufola I, et al.  Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLoS One. 2017; 12(3): e0173617. doi: 10.1371/journal.pone.0173617. 
  3. Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: A 2012 update. Prev Chronic Dis. 2014; 11:E62. doi: 10.5888/pcd11.130389. 
  4. Statistics Canada. Research highlights on health and aging. [Internet] 2015. [cited January 2019]. Available from https://www150.statcan.gc.ca/n1/pub/11-631-x/11-631-x2016001-eng.htm 
  5. Centers for disease control and prevention. Multiple chronic conditions. [Internet] 2018. [cited January 2019]. Available from https://www.cdc.gov/chronicdisease/about/multiple-chronic.htm 
  6. Coulter A, Entwistle VA, Eccles A, et al. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015; 3(3): CD010523. doi: 10.1002/14651858.CD010523.pub2. 
  7. Epping‐Jordan JE, Pruitt SD, Bengoa R, et al. Improving the quality of health care for chronic conditions. Qual Saf Health Care. 2004; 13(4):299‐305.
  8. Nolte E, McKee M. Integration and chronic care: A review. In: Nolte E, McKee M editor(s). Caring for people with chronic conditions: A health system perspective. Maidenhead, UK: McGraw Hill, 2008:64‐91.
  9. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998; 1(1):2–4.

DISCLAIMER: The blogs are provided for informational purposes only. They are not a substitute for advice from your own healthcare professionals.

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