title: Patient-centered plan-of-care tool for improving clinical outcomes.
abstract: OBJECTIVE
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medicine, Henry Ford Medical Group, USA. nrocco1@hfhs.org
authors.forename: Nicole
authors.initials: N
authors.lastname: Rocco
authors.forename: Katherine
authors.initials: K
authors.lastname: Scher
authors.forename: Barbara
authors.initials: B
authors.lastname: Basberg
authors.forename: Swaytha
authors.initials: S
authors.lastname: Yalamanchi
authors.forename: Kimberly
authors.initials: K
authors.lastname: Baker-Genaw
mesh_terms: D000369:Aged, 80 and over; D000818:Animals; D001794:Blood Pressure; D001835:Body Weight; D008078:Cholesterol, LDL / Q000097:blood; D002908:Chronic Disease; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning / Q000458:organization & administration*; D010358:Patient Participation / Q000379:methods*; D018802:Patient-Centered Care / Q000458:organization & administration*; D010817:Physician-Patient Relations; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D008078:Cholesterol, LDL; D006442:Glycated Hemoglobin