• Text Resize A A A
  • Print Print
  • Share Share on facebook Share on twitter Share

Module 1: Person- and Family-Centered Care (PERS)

Thumbnail of downloadable Module 1 PPT Presentation.

Healthcare that involves persons living with multiple chronic conditions (PLWMCC) and their families in every decision, and that empowers them to be partners in their own care1.

Making the Case for Person- and Family-Centered Care for Multiple Chronic Conditions (MCC)

Persons Living with Multiple Chronic Conditions (PLWMCC) usually require complex care delivered in primary care settings, with ongoing involvement of specialist providers2,3.  A holistic approach should address multiple physical health problems, medication management, development of treatment plans, home and community-based services, as well as complex psychosocial needs, including coordination of financial resources.  This type of care requires a team approach that includes PLWMCC, their families and caregivers, and their healthcare team5,6. Such partnerships are essential for priority setting, communication, satisfaction, and coordination of care4. Fostering these partnerships, focusing on the context in which a person is managing MCC on a daily basis, and developing a person-centered care plan that is based on the individual’s treatment and outcome goals are key to providing this type of care.  Person- and family-centered care for PLWMCC means changing the conversation from “what is the matter”, to “what matters to you?”7

Person- and family-centered care recognizes that emotional, social, and developmental support is central to maximizing the health and well-being of PLWMCC and their families and caregivers. Person- and family-centered care respects the values, needs, and preferences of PLWMCC and applies the best evidence-based care toward a shared goal of optimal function, health and quality of life10.

To fully integrate a person- and family-centered approach requires training of healthcare professionals in person- and family-centered care planning9.   By sharing evidence-based health information, PLWMCC receive timely, complete, and accurate information to support effective participation in care and decision-making5,6.  The benefits of incorporating the perspectives of PLWMCC and their families and/or caregivers include better outcomes, improved care, and increased satisfaction10-13.

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators.   The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, psychiatrists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams.   These competencies apply across the educational continuum, and can be discipline-specific or interprofessional.  Examples of learning objectives are provided below.  Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.  

PERS 1. Participate with PLWMCC and their families and caregivers in identifying and prioritizing their preferences when developing a care plan1.

Learning Objectives:

  1. Use shared decision-making techniques to select preference-sensitive* treatment options in collaboration with PLWMCC and their families and caregivers, as appropriate.
  2. Apply iterative quality improvement strategies, such as the Plan, Do, Study, Act (PDSA) to assess and improve care plans.

*“Preference-sensitive care comprises treatments for conditions where legitimate treatment options exist.”  For additional explanation see: http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2938


PERS 2. Include life context and social and cultural determinants of health when negotiating goals and plans of care with PLWMCC.

Learning Objectives:

  1. Maximize participation and engagement of PLWMCC and/or their families and caregivers in developing their care plans.
  2. Include life context and social factors when negotiating treatment goals and modifying care plans.
  3. Modify care plans timely as changes occur in the PLWMCC’s life, health, and unexpected circumstances.


PERS 3. Assist PLWMCC in reaching their identified lifestyle, management and treatment goals.

Learning Objectives:

  1. Ask PLWMCC to articulate their lifestyle, management, preferred service setting, and treatment goals. 
  2. Provide resources (community, clinical, peer support and other) to help PLWMCC achieve their management, preferred service setting and treatment goals.
  3. Employ behavior-change techniques to assist PLWMCC in reaching their identified lifestyle goals. *

*Examples include the Transtheoretical Stages of Change or the "5 A's": Ask, Advise, Assess, Assist, and Arrange


PERS 4. Provide care that is responsive to the preferences, needs and values of PLWMCC, and ensures that their values guide all clinical decisions.

Learning Objectives:

  1. Develop person-centered care plans that incorporate the preferences, needs and values of PLWMCC.
  2. Integrate healthcare and social services to promote physical and emotional well-being.
  3. Ensure that complex psychosocial needs are addressed. 


PERS 5. Provide care that is focused on the desired outcome(s) of PLWMCC.

Learning Objectives:

  1. Share risk management assessments with PLWMCC of the benefits and consequences of focusing on their preferred outcomes.
  2. Negotiate care plans that focus on the outcomes of interest to PLWMCC.


PERS 6. Assist PLWMCC, as needed, with coordination of financial resources to optimize quality of care.

Learning Objectives:

  1. Maintain current price lists for commonly used durable equipment.
  2. Post instructions in the waiting room on how to file applications for insurance through the Health Insurance Marketplace.*

*Local State Health Insurance Assistance Programs (SHIP) can assist with any insurance, including the marketplace.  


Selected Curricular Resources

The following is a list of curricular resources that address Person- and Family-Centered Care.   Additional resources and links can be found in the MCC Education and Training Repository.

The Health Mentors Program: A Longitudinal Chronic Illness Mentorship Program

Teaching Principles of Managing Chronic Illness Using a Longitudinal Standardized Patient Case

Primary Care of Older Adults Program (PCOA) e-Learning Modules

An Interprofessional Approach to Chronic Conditions 5: Caregiver and Family Support in Managing Chronic Conditions



1.   Institute of Medicine (US). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.
2.   Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Q, 74(4), 511-544.
3.   Glasgow, R. E., Orleans, C. T., & Wagner, E. H. (2001). Does the chronic care model serve also as a template for improving prevention? Milbank Q, 79(4), 579-612, iv-v.
4.    Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). J Am Geriatr Soc, 60(10), 1957-1968.
5.    Giovannetti, E. R., Wolff, J. L., Xue, Q. L., Weiss, C. O., Leff, B., Boult, C., Hughes, T., & Boyd, C. M. (2012). Difficulty assisting with health care tasks among caregivers of multimorbid older adults. J Gen Intern Med, 27(1), 37-44.
6.    Boyd, C. M., Wolff, J. L., Giovannetti, E., Reider, L., Weiss, C., Xue, Q. L., Leff, B., Boult, C., Hughes, T., & Rand, C. (2014). Healthcare task difficulty among older adults with multimorbidity. Med Care, 52 Suppl 3, S118-125.
7.    Bayliss, E. A., Bonds, D. E., Boyd, C. M., Davis, M. M., Finke, B., Fox, M. H., Glasgow, R. E., Goodman, R. A., Heurtin-Roberts, S., Lachenmayr, S., Lind, C., Madigan, E. A., Meyers, D. S., Mintz, S., Nilsen, W. J., Okun, S., Ruiz, S., Salive, M. E., & Stange, K. C. (2014). Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam Med, 12(3), 260-269.
8.    Starfield, B. (2011). Is patient-centered care the same as person-focused care? Perm J, 15(2), 63-69.
9.    Wrede, J., Voigt, I., Bleidorn, J., Hummers-Pradier, E., Dierks, M. L., & Junius-Walker, U. (2013). Complex health care decisions with older patients in general practice: patient-centeredness and prioritization in consultations following a geriatric assessment. Patient Educ Couns, 90(1), 54-60.
10.  Siminoff, L. A. (2013). Incorporating patient and family preferences into evidence-based medicine. BMC Med Inform Decis Mak, 13 Suppl 3, S6.
11.  Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood), 32(2), 207-214.
12.  Hibbard, J. H., Greene, J., & Overton, V. (2013). Patients with lower activation associated with higher costs; delivery systems should know their patients' 'scores'. Health Aff (Millwood), 32(2), 216-222.
13.  Koh, H. K., Brach, C., Harris, L. M., & Parchman, M. L. (2013). A proposed 'health literate care model' would constitute a systems approach to improving patients' engagement in care. Health Aff (Millwood), 32(2), 357-367.
14.  Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., Carlsson, J., Dahlin-Ivanoff, S., Johansson, I. L., Kjellgren, K., Liden, E., Ohlen, J., Olsson, L. E., Rosen, H., Rydmark, M., & Sunnerhagen, K. S. (2011). Person-centered care--ready for prime time. Eur J Cardiovasc Nurs, 10(4), 248-251.
15.  Lee, Y. Y., & Lin, J. L. (2010). Do patient autonomy preferences matter? Linking patient-centered care to patient-physician relationships and health outcomes. Soc Sci Med, 71(10), 1811-1818.
16.  Venetis, M. K., Robinson, J. D., Turkiewicz, K. L., & Allen, M. (2009). An evidence base for patient-centered cancer care: a meta-analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns, 77(3), 379-383.
17.  Okun, S., Schoebaum, S.C., Andrews, D., Chidambaran, P., Chollette, V., Gruman, J., Leal, S., Lown, B.A., Mitchell, P.H., Parry, C., Prins, W., Ricciardi, R., Simon, M.A., Stock, R., Strasser, D.C., Webb, C.E., Wynia, M.K., and Henderson, D. . (2014). Patients and Health Care Teams Forging Effective Partnerships Discussion paper. Washington, DC: Institute of Medicine
18.  Montgomery, K., & Little, M. (2011). Enriching patient-centered care in serious illness: a focus on patients' experiences of agency. Milbank Q, 89(3), 381-398.
19.  Bolster, D., & Manias, E. (2010). Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study. Int J Nurs Stud, 47(2), 154-165.
20.  Miller, D., Steele Gray, C., Kuluski, K., & Cott, C. (2014). Patient-Centered Care and Patient-Reported Measures: Let's Look Before We Leap. Patient.
21.  Fitzgerald, S. P., & Bean, N. G. (2010). An analysis of the interactions between individual comorbidities and their treatments--implications for guidelines and polypharmacy. J Am Med Dir Assoc, 11(7), 475-484.
22.  Ridgeway, J. L., Egginton, J. S., Tiedje, K., Linzer, M., Boehm, D., Poplau, S., de Oliveira, D. R., Odell, L., Montori, V. M., & Eton, D. T. (2014). Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Prefer Adherence, 8, 339-351.
23.  Hartford Institute for Geriatric Nursing and Health Resources and Services Administration (HRSA). Primary Care of Older Adults Program (PCOA) e-Learning Modules. (2014).
24.  Rathert, C., Wyrwich, M. D., & Boren, S. A. (2013). Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev, 70(4), 351-379.
25.  Ickowicz, E. (2012). Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society Journal of the American Geriatrics Society 60(10), 1957-1968.
26.  Rocco, N., Scher, K., Basberg, B., Yalamanchi, S., & Baker-Genaw, K. (2011). Patient-centered plan-of-care tool for improving clinical outcomes. Qual Manag Health Care, 20(2), 89-97.


Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015