Patient Priority Care for Older Adults With Multiple Chronic Conditions Achieved Through Primary and Specialty Care Alignment
Phase: NA
Conditions: Multiple Chronic Conditions
Sponsor: The Cleveland Clinic

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Introduction   
 
Healthcare for older adults with multiple chronic conditions (MCCs) is burdensome and of uncertain 
benefit, resulting in unwanted and unhelpful care. Patient Priorities Care (PPC) is an approach that aligns 
care with patients’ health priorities (i.e. the health outcomes most desired given the healthcare each is 
willing and able to receive). PPC offers the opportunity to increase value by improving both outputs 
(desired health outcomes) and inputs (healthcare preferences) for these major users of healthcare.  
 
The ultimate goal of our work is to implement and evaluate this approach to care for older adults with 
multiple chronic conditions that focuses on what matters most to them and is less fragmented and 
burdensome, resulting in better quality and outcomes at lower cost. This study will focus on evaluating 
practice change at test sites at the Cleveland Clinic.  
 
 
Background and Significance 
 
The 60-70% of older adults with multiple chronic conditions (MCCs) are major recipients of healthcare.1 
Much of this healthcare is burdensome and of uncertain or modest benefit.2 Most evidence is generated in 
persons with few conditions and assessed by survival or disease-specific outcomes that may not be what 
matters most to this population who vary in their outcome priorities.2-8 The burden imposed by caring for 
MCCs is increasing.9,10 Medicare patients with MCCs spend an average 33 days per year in contact with 
the healthcare system and two hours a day on healthcare-related activities.11,12 Cost to the health system 
(primarily Medicare) accounts for the bulk of the medical spending among older adults. Out of pocket 
expenses are growing.13 Some of this care may be harmful.14 The uncertain benefit, treatment burden, 
potential harm, and rising costs all call into question the value of healthcare for older adults with MCCs. 
True value-based care must be of value to individuals, health systems, and payers.15 Health systems view 
value based not only on benefits to the system, but also to the patients they serve. In considering value 
from a patient’s perspective, the personal health outcomes that they hope to achieve – which vary for 
older adults with MCCs - are the appropriate outputs.6,16 The inputs include financial costs and indirect 
costs in terms of the health-related workload.16 When defined as what patients are willing and able to do, 
the indirect costs inform healthcare preferences.17 Patients’ desired health outcomes given their healthcare 
preferences constitute their health priorities.17-20 Patient Priorities Care aligns healthcare with patients’ 
health priorities.17-20 We now aim to evaluate its value within the Cleveland Clinic.  
 
Healthcare utilization and costs associated with age and MCCs are well known.1,21 Persons ≥65 years are 
15% of the U.S. population but consume 34% of health care expenditures, including both community-
based care and hospitalization.21,22 Approaches for improving care of older adults with MCCs have been 
investigated. 21-25 A systematic review of 18 systems- or patient-based interventions - none addressing 
patients’ priorities - revealed modest effect on patient-reported outcomes but little or no effect on 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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healthcare utilization; cost data were limited.24,25 Some interventions targeting specific health problems, 
particularly among persons with advanced illness, have proven cost-effective in the hospital setting; less 
in known about cost-effectiveness in the ambulatory setting.26-35   
 
Compared to patients receiving usual care (UC) in a recent study, those receiving PPC reported greater 
decrease in treatment burden (a major concern for older adults with MCCs), had more medications 
stopped and fewer self-management tasks and diagnostic tests ordered.36  
 
To determine the value of PPC, comparable primary care sites within the Cleveland Clinic will be 
assigned to PPC or UC. Clinicians and staff at the PPC site will be trained to identify and align decision-
making with the health priorities of older adults with MCCs. Value will be compared using patient and 
provider-reported outcomes, healthcare utilization, and possibly costs at PPC and UC sites.  
 
 
Hypothesis/Research Question 
 
Does aligning healthcare with patients’ health priorities (their most desired health outcomes given the 
healthcare activities they are willing and able to do) increase value? 
 
 
 
Study Design 
 
Methods 
We will employ a quasi-experimental, usual care (UC) group design, involving 2 primary care sites (1 
PPC and 1 UC. Patients are assigned to intervention or usual care arms based on their primary care 
practice location. We will use analytic techniques (e.g., inverse propensity score weighting) designed to 
reduce selection bias and balance PPC and UC sites in terms of baseline characteristics.  Data collection 
will occur through quantitative and qualitative interviews and health encounter information in the EHR. 
 
Patient Priorities Care requires the elicitation and documentation of patient health outcome goals and care 
preferences and the alignment of clinical care with goals and priorities to achieve patients’ health outcome 
goals and reduce the burden of multi-morbidity.  Participants will be enrolled in the Patient Priorities Care 
Program and speak with a trained health priorities facilitator to elicit their healthcare preferences and 
health outcome goals, which together constitute their health priorities.  This information will be 
documented, entered into the EHR, and shared with the clinicians who will then use the Patient Priorities 
Care approach with patients to inform and guide treatment decisions.  Patients will participate in the 
program and be followed for up to one year from the health priorities identification visit. 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Sample 
Patients: Potentially eligible participants for this project include Medicare beneficiaries (Traditional, 
Medicare Advantage, and dual eligible) 66 years or older who are patients of participating clinicians. 
 
We assessed the power to detect clinically relevant differences in Patient-Reported Outcomes (PROs) and 
categories of healthcare utilization, both needed to measure value. We calculated minimal detectable 
differences for the primary PPC outcomes based on a sample size of 500 participants (250 PPC and 250 in 
UC) that assumed 80% power, a one-tailed alpha of 0.05, and an R-squared of 0.2 from other covariates. 
Assuming a standard deviation of 24.1 at pre-test and 17.6 at post-test and a correlation between 
measurement pairs of 0.55 (based on pilot data) allows us to detect a between-group difference in mean 
change in the TBQ score from pre-test to post-test of -4.6 points.37 Comparing the PPC group to the UC 
care group, our sample permits us to detect an odds ratio of 1.7 with respect to discontinuing medications 
and an odds ratio of 0.52 with respect to having diagnostic tests ordered.38 
 
 
Inclusion/Exclusion Criteria 
The evaluation of PPC in the clinical practice will take place as part of the patient’s ongoing healthcare, 
and is minimal risk. Criteria for inclusion in the clinical program will be expansive in order to offer the 
opportunity for the largest number of reachable patients possible. All recruits will be those who are 
currently patients at Cleveland Clinic.  Patient’s meeting any of the exclusion criteria will not be 
approached by the Cleveland Clinic clinicians.  
 
Inclusion Criteria: 
1. Age 66 and older 
2. In the Cleveland Clinic patient population 
3. In the clinician practices selected as intervention or usual care practice sites 
4. Clinically identified by: Those who meet any of several criteria  
i. 
3 chronic conditions (See appendix 0 for the complete list) 
ii. 
10 medications  
iii. 
>2 ED visits over the past year 
iv. 
>1 hospitalization (or >10 days in hospital)  
v. 
receive any care coordination services  
vi. 
2 specialists over past year  
 
Exclusion Criteria: 
1. In hospice or meeting hospice criteria for any condition 
2. Advanced dementia or moderate to profound intellectual disabilities  
3. Not English speaking 
4. Nursing home resident 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Primary Care providers (PCPs) and Health Priorities Facilitators:  PCPs are identified at the 
intervention site by screening the clinic’s electronic health records (EHR) to identify those clinicians with 
eligible patients in their clinic panels.  This requires a waiver of consent and waiver of HIPAA 
authorization.  Potential priorities facilitators were identified by examining existing resources and finding 
most appropriate care givers within the facility (Appendix.1).  Employee Study Information sheet will be 
personally distributed in advance.  Research team will directly contact potential clinicians and facilitators, 
and allow them to review our intervention and expected roles. If potential clinicians and facilitators 
express interest in the project, they will be also asked to confirm their willingness to complete one hour 
over-the-phone training session and one half-day training session to be familiar with the intervention 
process in addition to review of online training materials. At this point, no protected health information or 
patient identifying information is collected or recorded.  
 
 
Procedures 
 
The subject for this IRB protocol is the implementation and evaluation of the Patient Priorities Care 
process that will be implemented in clinical sites at the Cleveland Clinic (CC). The CC Patient Priorities 
Care team including, primary physicians, and health priorities facilitators (i.e. Geriatrician, Medical 
Assistant, Care Coordinators, and Patient Liaison Program Coordinators, Nurse practitioners) along with 
other logistically necessary individuals, will help patients elicit their health outcome goals and healthcare 
preferences. The elicitation of patient priorities will be embedded into CC clinical programs routinely 
offered to patients (Appendix 1).  
Table 1. Schedule of Evaluation for Patient Population 
Clinical 
Procedures 
 
 
 
Goal 
Facilitation 
Visit(s) 
PPC 
Clinician 
Visit(s) 
Goal 
Facilitator 
Follow up 
 
 
 
 
Research 
Procedures 
 
Pre-
Screening 
Baseline 
Interview 
 
 
 
 
Follow 
up 
interview 
Follow 
up 
 
Week 
Up to -7 
-5 to 0 
-6 to -1 
0 
2 to 6 
(1-2wk after 
1st PCP) 
 
34 to 52 
 
Up to 
52 
 
Month 
 
-1 
-1 
0 
1-2 
 
8 – 12 
12 
 
 
Intervention 
arm 
Consent 
 
x 
 
 
 
 
x 
 
EHR data extraction 
 
x 
 
 
 
 
 
x 
Identification/ 
discussion  of  
patient health priorities 
 
 
x 
x 
x 
 
 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
 Version Date: 07-22-2021                                                                                                                                       Page 5 of 21 
 
 
 
 
 
Interview  
• 
Demographics 
• 
5-word recall* 
• 
PROMIS 
• 
CollaboRATE 
• 
Tx Burden 
questionnaire 
 
x 
 
 
 
 
x 
 
PCP visit 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Usual care 
arm 
Interview  
• 
Demographics 
• 
5-word recall* 
• 
PROMIS 
• 
CollaboRATE 
• 
Tx Burden 
questionnaire 
 
x 
 
 
 
 
x 
 
PCP visit 
 
 
 
x 
 
X
X
X 
 
 
 
EHR data extraction 
 
x 
 
 
 
 
 
x 
*Baseline in-person interview only. 
 
Patients meeting criteria within the Cleveland Clinic Lakewood Family Health Center (FHC) and 
Brunswick FHC patients who are scheduled to have visit during study period will be recruited using mail, 
or My Chart message about the project taking place.  Lakewood FHC will be serving as intervention site 
and Brunswick FHC as usual care. Eligible and consented patients will participate in the program and be 
followed for up to one year from the goal elicitation visit.  Primary physicians, and priorities facilitators 
(i.e. Geriatrician, MAs, Care Coordinators, Patient Liaison Program Coordinators, and Nurse 
practitioners) will undergo training and preparation to elicit and provide care aligned with health 
priorities. This training has been developed and tested during the Yale University pilot study of Patient 
Priorities care.  
 
Pre-screening and Recruitment (Research procedure) 
 
A list of patients meeting above criteria will be generated by the methods described below, and provided 
to PCPs to obtain their permission to invite patients.  PCPs may suggest removing any patients who may 
not be appropriate for the intervention at PCP’s discretion.  Research team will conduct a baseline 
interview after obtaining verbal consent from the patients. Priorities Facilitators will be notified to invite 
these patients to have their health priorities identified and their care aligned with these priorities. To 
maximize flexibility and align with current workflow, the invitation for priorities identification can be 
during a regular visit, by phone, by mail, or other means already used by the practices (e.g. same visit as 
invitation; part of annual wellness visit, etc.).   

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Project specific generated list: Each week, a scheduling system will provide an automated list of 
targeted patients with appointments 6 weeks later.  Appointment types include in-person office visit, 
distance health, virtual, or telephone visit.  This system is linked with EHR and widely used at our 
institution.  Once target patients are identified and approved by the PCP, research personnel will 
contact via mail, or My Chart messaging to introduce the Patient Priorities Care program with an 
information sheet to explain the Patient Priorities Care process and ask them to contact the research 
team if they want to opt out.  Opt-out patients will be recorded in the screening log to avoid contacting 
again for future recruitment. 
 
Care providers referral: Care providers can make a referral if they have patients who could benefit 
from the Patient Priorities Care program, otherwise meet inclusion and exclusion criteria, and have 
regular visits in next few months.  Care providers can discuss the program and provide information 
sheet to the potential participants.  Clinician will notify the research team of the potential patients who 
have agreed to participate in the PPC.  Research team will contact these potential participants to 
obtain consent to participate in Patient Priorities Care before asking any research questions.  Care 
providers will also notify names of patients who decline to participate in order to avoid contacting the 
same patients again for future recruitment. 
 
Primary Care Coordination patients list: For patients enrolled through the Care Coordination 
program, research personnel will identify the individuals ahead of time and obtain permission from 
their PCPs.  Research team will contact via mail, or My Chart messaging to introduce the Patient 
Priorities Care program with an information sheet to explain the Patient Priorities Care process and 
ask them to contact research team if they want to opt out.  After excluding patients who opted out, 
research personnel will contact patients to obtain consent and conduct baseline interview.  Because 
this project provides prioritized patients’ list based on their existing Care Coordination patient list for 
the Coordinators to reach out, this process adds very little burden on Care Coordinator’s part. 
 
Usual care Group  
Concurrent to the Patient Priorities Care implementation, we will begin to identify the usual care group 
which will include up to 250 patients. We will identify a sample similar to the intervention group, using 
the same inclusion/exclusion criteria and clinical judgment.  The usual care group will be identified from 
Brunswick FHC patients.   
The usual care group will be identified through the same electronic health record search and Care 
Coordination patient list described above, and PCPs will have the option of not including any of their 
patients for interview for usual care group.  
 
The usual care group during the study period will receive a recruitment letter from their clinician 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
 Version Date: 07-22-2021                                                                                                                                       Page 7 of 21 
 
 
 
 
 
describing the research and interview. Patients will be able to opt-out if they do not wish to be contacted 
by contacting research team listed in the invitation letter. For patients who do not opt-out, a centralized, 
trained research personnel will contact candidates by phone to confirm eligibility and to obtain verbal 
consent for enrollment in the usual care arm which involves standard clinical care, data collection through 
an interview, and a medical record review.  
 
 
Consent process 
We will require a full waiver of consent and HIPAA authorization for the health care utilization data that 
will be used as part of the screening process and evaluation of the patient population. We will also request 
a waiver of signed consent and HIPAA authorization for participation of clinicians and patients in the 
research evaluation. It would be impractical to gain signed consent for this information, specifically for 
this population and the research involves minimal risk.  
 
Consent process will be conducted primarily over the phone by a trained project staff member. Patients 
will be notified via letter, My Chart message or phone that a CCF research personnel will be contacting 
them to conduct the interviews.  A trained research coordinator will administer the qualitative survey. 
Participants in both intervention and usual care groups will receive $10 for each research interview for a 
total reimbursement of up to $20.   
 
Baseline interview 
Once potential patients are identified, research personnel will add participants’ contact information into a 
secure electronic data collection system (REDCap) which the research team will also use to contact the 
participants to administer the interview.  Up to 6 weeks prior to their next PCP appointment, selected 
patients will be contacted by phone or in-person to confirm consent to participate. Once eligibility is 
confirmed, research personnel conduct phone or in-person baseline interview whichever is preferred by 
the patient.  Baseline interview could follow after Priorities Facilitators (Geriatrician, MA, Care 
coordinator, Patient Liaison Program Coordinators, Nurse Practitioners) completes priorities identification 
process.  This can be done before or the day of the initial PCP visit to begin deciding treatment plans 
based on priorities.  Contact information will be stored separately from interview and medical record data 
and destroyed once the follow-up interviews have been conducted and data collection and cleaning is 
complete. 
 
Priorities Facilitators will help patients identify their health priorities, complete the health priorities 
template in EHR.   Please note that similar process has been routinely done at the clinic as part of Care 
Coordinators’ and Patient Liaison Program Coordinators’ job (Appendix 1), and this project provides 
more structure in documentation and collaboration with other care providers involved. 
 
PCPs will be asked to review the patients’ health priorities at subsequent clinical follow up visits and 
update if necessary. 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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At the intervention site, we will identify site champions to develop continued buy-in from providers (e.g., 
staff meetings, individual meetings, case examples), obtain feedback, and notify the PI and research team 
of unanticipated problems.  
 
 
Intervention (Clinical procedure) 
Patient Priorities Care is an innovative approach to shared decision-making that draws from existing 
professional training (e.g. clinical competencies, motivational interviewing, and geriatrics care). Patient 
Priorities Care requires the elicitation and documentation of patient health outcome goals and care 
preferences and the alignment of clinical care with health goals and healthcare preferences (collectively 
referred to as health priorities) Participants will be enrolled in the Patient Priorities Care Program and 
communicate with a trained priorities facilitator in-person or over the phone to elicit their health priorities.  
This information will be documented in the PPC- GOALS AND PREFERENCES form in the EHR and 
shared with the clinicians who will then use the Patient Priorities Care approach with patients to inform 
and guide treatment decisions.   
Patients will participate in the program and be followed for up to one year from the priorities elicitation 
visit by the research team.  The target follow-up time is 8-10 months. The PCPs will be trained in 
decisional strategies that have been shown to help align care with patients’ health priorities. While 
encouraged to use these decisional strategies, PCPs will be free to make the recommendations they feel 
most appropriate for each patient. 
This intervention has been developed to be integrated seamlessly into usual care, and does not involve any 
research aspect such as program development, data collection, and evaluation at all.  Documentation 
completed by Facilitators is considered part of standard clinical care.  Intervention development, data 
collection and evaluation including follow up data collection are conducted by the research team.  What 
PCPs and facilitators are asked to perform for this project is within their standard scope of work.  The 
intervention does not require additional visits or substantially increased provider time for PCPs as the 
Goals and Preferences information collected by the Facilitator will be used as decision aid during regular 
office visits. However, it is to the providers’ discretion, to spend as much time as needed if that would 
benefit the participating patient.  
 
 
 
Priorities Facilitators 
The Priorities Facilitators will be trained health professional (i.e. Geriatrician, MA, Care Coordinators, 
and Patient Liaison Program Coordinators, Nurse practitioners).   
Responsibilities 
1. Undergo training and preparation to elicit and document patients’ health priorities  
2. Elicit priorities using PPC point-of-care materials.  

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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3. Provide a copy of completed PPC- GOALS AND PREFERENCES form to the PCP before the 
PCP visit and encourage patients to bring this up during their PCP visit. 
4. Communicate these health priorities to the Primary Care Provider through verbal discussion 
and/or documentation into the patient’s Electronic Health Record (EHR). prior to the PCP visit. 
5. Enter the identified health priorities into Electronic Health Record (EHR) and provide to patients 
(as applicable). 
6. Contact enrolled patients to follow up 2-3 weeks after the initial PCP visit and assist in building a 
partnership between patient and clinician.  
7. Review health priorities and update as needed 
 
Clinicians  
The clinician will be a licensed health care professional (MD, APRN, PA). Visits can be in-person, 
virtual, or phone visits. 
Responsibilities 
1. Participate in health priorities aligned care training that includes a 2 hour face to face session 
followed by ongoing short review sessions 
2. Know or review patient’s health priorities template provided by the priorities facilitators, align 
care decisions to each patient’s health priorities ”  
3. Decision making moves  
a. From: You need (fill in blank) for your (fill in blank). 
b. To: There are different things that we could do. But knowing your conditions, your overall 
health, and your health outcome goals and care preferences (what matters most to you), I 
suggest we try (fill in the blank).  
4. Translate patient’s health priorities into care options with guidance from point-of-care materials, 
decisional guidance and strategies, , and clinician champions  
5. Participate with patients/caregivers in shared decision-making around health priorities 
6. Review, discuss, and update patient’s health priorities or refer to priorities facilitator for further 
discussion 
7. Include patient health priorities in clinical communications such as referrals, consults, and clinical 
notes.  
8. Discuss with specialists (e.g. cardiologists) as needed to ensure care is aligned with patient’s 
priorities 
9. Document discussions and decisions in EHR (SMART phrases) 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
 Version Date: 07-22-2021                                                                                                                                       Page 10 of 21 
 
 
 
 
 
Follow up data collection (Research procedure) 
Follow up data collection will be two-fold: We’ll conduct phone (or in-person) interview and ask the 
same questions except cognitive ability screening items at 8-10 months from the baseline; and we’ll 
collect patient-level utilization and other clinical variables from EHR from 3 months prior to baseline 
date through up to 12 months after the baseline date.  
 
Follow up interview: Approximately 9 months from the PCP visit, follow up interview will be 
conducted by phone or in-person.  All patients who participated in the intervention will be contacted 
at 9 month (+/- 30 days protocol window) to complete follow up interview defined in the variable list. 
A week prior to follow up interview period, research personnel will send mail/My Chart message or 
call to remind participants of the follow up interview session. If participant does not respond to the 
follow up interview invitation by the 9th month, we will follow up with a letter with the interview form 
and self-addressed, stamped envelope enclosed.  We will ask patients to fill the forms and send back 
by mail. 
       
Post-Follow up interview: Research personnel will contact enrolled patients who completed follow 
up interview for missed question items from the follow up interview by calling messaging. If an 
enrolled participant does not respond to the Post-follow up interview invitation by the 12th month from 
baseline, we will follow up with MyChart message or a letter with the interview form and self-
addressed, stamped envelope enclosed.  We will ask patients to fill the forms and send back by 
MyChart message link or mail. This procedure only apply to enrolled patients who completed follow 
up interview but missed questions due to Redcap programing error reported on 7/15/2021 as 
Unanticipated Problem. 
 
Data extraction: From 3 months prior to Baseline Interview through up to 1 year from the Baseline 
Interview, the following information will be ascertained from patients who gave consent:   The 
number and types of chronic conditions (collected at Baseline only), medications, Healthcare activities 
defined as below, ACP (Advance Care Planning) tab use, and the Accountable Care Organization 
(ACO) survey as defined below. 
 
 
Data Collection overview 
In the 2 participating sites (Lakewood and Brunswick) the following information will be collected:  
 
• Demographic variables listed in the data collection sheet will be ascertained during the baseline 
telephone interview or via EHR review. During the baseline interview, physical and mental health will 
be ascertained with PROMIS-10,39 while the modified version of cognitive ability screening (5-word 
memory test) will assess patient’smemory.40 Number and types of chronic conditions and medications 
will be ascertained from the EHR. 
 
•  In addition to measuring self-reported physical and mental health with PROMIS-10, we will assess 
patients’ perceptions of whether their healthcare was collaborative and focused on their goals with 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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CollaboRATE.41 Perceived treatment burden will be assessed by the Treatment Burden 
Questionnaire.42 “As part of their ACO quality measures, Cleveland Clinic is focusing on shared 
decision-making around new medications. We will track responses to the current question on the ACO 
survey, “When starting a new medication, did your provider ask what you thought was best for you?”  
These PROs will be ascertained at baseline and after approximately 9 months follow-up by a trained 
assessor. 
 
• The number (%) of participants with the following healthcare activities will be abstracted from EHR 
orders and visit notes:1) medications;  2) self-management tasks; 3) diagnostic tests 4) referrals; and 
5) procedures A data dictionary which guided uniform abstraction in two PPC pilot studies will be 
used. Inter-rater reliability between two coders was excellent (κ = 0.89, 95% CI [0.85, 0.95], p < 
.001.2 Healthcare costs may be estimated by calculating local costs for each activity or service. 
Hospitalizations and emergency (ED) visits and costs will also be tracked. Time spent in  ambulatory 
healthcare activities, ED visits, and hospital stays will also be used to ascertain healthcare contact 
days.43 
 
• Time required to prepare for, and participate in, patient priorities-aligned decision-making is essential 
to defining value from the health system perspective. To estimate the time required to implement PPC, 
research team will work with a process improvement member of PPC practice to build workflows for 
the tasks needed to carry out PPC by staff and clinicians and calculate the time spent on each task 
based on interviews and observations. A similar process was used in the PPC pilot study.44 Time can 
be converted to dollars using local costs for relevant clinicians and staff. 
 
Clinician feedback  
Following the completion of patient recruitment, we will ask each PCP and priorities facilitator for 
both quantitative and qualitative feedback, including those with both favorable and unfavorable opinions. 
The quantitative survey was developed and used by investigators implementing PPC in a VA clinic in 
Texas. We will contact clinicians by email, telephone and in-person, to request their completion of the 
survey.  
 
 
COVID-19 Procedures (Remote Research Procedures) 
As already described above, entire research procedures including recruitment, consent, baseline interview, 
Facilitation visit, PCP visits, and follow up interviews, could be performed without direct in-person 
interactions with participants.  The core of the intervention is facilitating discussion among Priorities 
Facilitator, PCP and patient, regardless of communication modes.  We’ll examine if there is any 
mediating effects in results when comparing in-person and phone/virtual communication between patients 
and care providers. 
 
Data Analysis 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
 Version Date: 07-22-2021                                                                                                                                       Page 12 of 21 
 
 
 
 
 
 
We will calculate descriptive statistics for the intervention and usual care participants’ baseline 
characteristics and primary and secondary outcomes. Differences between the two groups’ post-test 
primary and secondary outcomes will be examined using generalized linear models (adjusting for baseline 
demographic, clinical characteristics and baseline outcome values). Model assumptions will be checked 
by, for example, inspecting residual plots and goodness-of-fit statistics.  To account for clustering of 
patients within medical practices, we will estimate models with robust standard errors. To minimize the 
loss of observations used in the analyses, we will use fully-conditional multiple imputation to address 
missing data. Comparability of participants in the two arms will be assessed by comparing the distribution 
of baseline characteristics in the two groups using appropriate graphical procedures, summary statistics 
and multivariable methods. If participants’ baseline characteristics appear to be unbalanced between arms, 
we will use inverse propensity score weighting to achieve covariate balance between the two groups. 
 
 
Data Confidentiality 
 
Data collection will be performed through the Cleveland Clinic Research Institute, by trained staff, using 
REDCap, and following Cleveland Clinic’s procedures for data protection and privacy. Data will be de-
identified before being transmitted to Yale University where it will be prepared for analysis by Yale 
Program on Aging data core staff.  
 
Chart abstraction of the patient’s health record (EHR) occurs at the end of the follow-up period.  
 
All data will be collected and recorded by trained personnel and stored on encrypted computers. PHI will 
be used only to identify patients eligible for the project. Only Cleveland Clinic clinical staff will have 
access to the identifiable data. Only de-identified data will be provided to the Yale investigators.  At no 
time will quantitative or qualitative interviews ask for PHI. All data collection, management, and analysis 
will occur on computers that are encrypted and servers that have appropriate firewalls. 
 
 
Potential Risks 
 
No more than minimal risk to training participants is expected from this research. For data from electronic 
health records, there is a potential risk for a breach in confidentiality. All efforts will be made to protect 
the confidentiality of the participants and their personal health information. We will use study ID numbers 
for patients so we can link clinical and interview data over the different time points. The data we send to 
the Yale team will use the study IDs and will not include patient names or medical record numbers. 
 
 
Protection against Risk 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Participant confidentiality will be maintained throughout the project in a way that ensures the 
information can always be tracked back to the source data. Where appropriate, a unique participant 
identification code (ID number) will be used that allows identification of all data reported for each 
participant. Participant information collected in these studies will comply with the standards for 
protection of privacy of individually identifiable health information as promulgated in the Health 
Insurance Portability and Accountability Act and as mandated in Title 45 CFR, Parts 160 and 164. All 
records will be kept confidential and names will not be released by research staff. Caution will be 
exercised to assure the data are treated confidentially and that provider and patient privacy is protected. 
To ensure awareness of and compliance with this procedure, all members of the research teams must 
undergo training on human subject protection and educated regarding the release of PHI for research 
purposes.   
 
Data will be stored on a password-protected server, which is protected behind a login and Secure 
Sockets Layer (SSL) encryption. Data will be analyzed using the common programming language and 
statistical packages. Data access will only be available to the principal investigator and authorized 
members of the research team. 
 
Electronic record backups are retained in a secure location to prevent catastrophic loss of data 
quality and integrity and to allow efficient resumption of clinical research following computer failures 
(see Resources). Electronic audit trials are maintained to protect the authenticity, integrity, and 
confidentiality. All electronic data systems are behind the Cleveland Clinic firewall. Entry to the 
continually locked research area is restricted by a coded badge identification system.  
 
The Principal Investigator is ultimately responsible for the conduct of the research protocol. The 
investigator ensures the research is conducted according to the IRB-approved protocol in compliance with 
federal regulations, all institutional policies, and ethical principles identified in the Belmont Report. The 
investigator will ensure that adequate resources are available to conduct the clinical trial and will provide 
supervision and oversight of all members of the research team. We will also perform data and safety 
monitoring throughout the study period. 
 
 
Potential Benefits 
 
The proposed work has potential to directly benefit research participants.  Patients will be provided with 
information that may improve their ability to interact with their clinicians and healthcare team make an 
informed decisions about their health care.  Patient Priorities Care conversations will be integrated as part 
of clinic standard of care (as part of goals of care conversations).  We expect that this approach will create 
an enhanced dialogue between patients and their clinicians and will result in better care for the individual. 
 
 
Cost 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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There is no cost for participation. This quality improvement project is being implementing as part of 
ongoing patient care at Cleveland Clinic. 
 
 
Data and Safety Monitoring Plan 
                                                                                                                                                        
Due to the minimal to no-risk nature of the project, the standard of care of these interventions, and the 
real-time interim data analyses as part of the quality improvement collaborative, a formal Data and Safety 
Monitoring Board is not necessary. Oversight and monitoring to ensure the safety of participants and the 
validity and integrity of the data will be ensured by the entire research team, with particular focus by the 
CCF research team.  The research team is committed to protecting participants’ privacy throughout the 
life of the project. At periodic intervals during the course of the project, the research team will: 
• Review the research protocol. 
• Evaluate the progress of the project. 
• Consider factors external to the project when relevant, such as scientific or therapeutic 
developments that may affect safety or ethics of the project. 
• Review performance, make recommendations, and assist in resolving problems. 
• Protect the safety of the participants. 
• If appropriate, conduct interim analysis 
• Ensure confidentiality of data. 
 
Problems with workflow and process will be reviewed by members of the Yale team with the CC 
research personnel and adjustments will be made as needed. Adverse events will be reported to the 
IRB as well as to the Yale team and Funders as they occur. Due to the nature of this project, there is 
minimal risk of adverse events.  
 
 
Consent 
 
The use of verbal permission is being requested.  The research personnel performing the baseline 
interviews, the health priorities facilitator or the participating clinician will obtain verbal permission from 
patients who received Patient Priorities Care during the first encounter with patient priorities care.  This 
will allow project staff to provide the pre/post qualitative and quantitative interviews/surveys over the 
phone but also obtain utilization data.  These research personnel, priorities facilitators and clinicians are 
or will be trained in obtaining verbal permission.   
The use of verbal permission will also ensure the safety of potential participants and be appropriate mode 
of communication during the COVID-19 pandemic. 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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For initial patient identification process, a waiver of HIPAA authorization is being requested to identify 
those participating in the clinical program. It would be impractical to gain consent from all the patients 
whose records will be viewed in order to identify appropriate individuals to invite to participate. These 
records are being viewed as part of ongoing clinical care, and the information will not be share with any 
personnel outside of CCF. 
 
References 
 
1. Chevarley, F.M. Expenditures by number of treated chronic condition, race/ethnicity, and age, 
2012. Statistical Brief #485. Rockville, MD: Agency for Healthcare Research and Quality; 2015. 
http://meps.ahrq.gov/mepsweb/data_files/publications/st485/stat485.pdf. Accessed February 21, 
2019. 
2. Boyd C, Smith CD, Masoudi F, Blaum CS, Dodson J, Green AR, Kelley A, Matlock D, 
Ouellet J, Rich MW, Schoenborn NL, Tinetti ME. Decision-making for Older Adults with 
Multiple Chronic Conditions: Executive Summary for the AGS Guiding Principles on the Care 
of Older Adults with Multimorbidity. J Am Geriatr Soc 2019. doi: 10.1111/jgs.15809. 
3. O'Hare AM, Hotchkiss JR, Kurella Tamura M, Larson EB, Hemmelgarn BR, Batten A, et al. 
Interpreting treatment effects from clinical trials in the context of real-world risk 
information: end-stage renal disease prevention in older adults. JAMA Intern Med. 
2014;174(3):391-7. 
4. Uhlig K, Leff B, Kent D, et al. A framework for crafting clinical practice guidelines 
that are relevant to the care and management of people with multimorbidity. J Gen 
Intern Med. 2014;29(4):670-679. 
5. Zulman DM, Sussman JB, Chen X, Cigolle CT, Blaum CS, Hayward RA. Examining the 
evidence: a systematic review of the inclusion and analysis of older adults in randomized 
controlled trials. J Gen Intern Med. 2011;26(7):783-790. 
6. Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome 
prioritization as a tool for decision making among older persons with multiple chronic 
conditions. Arch Intern Med. 2011;171(20):1854-1856. 
7. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: 
incorporating patient preferences in practice guidelines. JAMA. 2013;310(23):2503-
2504. 
 
 
 
8. Bayliss EA, Bonds DE, Boyd CM, et al. Understanding the context of health for persons 
with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam 
Med. 2014;12(3):260-269. 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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9. Tran VT, Harrington M, Montori VM, Barnes C, Wicks P, Ravaud P. Adaptation and 
validation of the Treatment Burden Questionnaire (TBQ) in English using an internet 
platform. BMC Med. 2014;12:109. 
10. Boyd CM, Wolff JL, Giovannetti E, et al. Healthcare task difficulty among older adults 
with multimorbidity. Med Care. 2014;52 Suppl 3:S118-125. 
11. Bynum JPW, Meara ER, Chang CH, Rhoads JM, Bronner KK, Our parents, ourselves: Health 
care for an aging population. Lebanon, NH: The Dartmouth Institute of Health Policy and 
Clinical Practice, 2016. 
12. Jowsey T, Yen L, Mathews P. Time spent on health related activities associated with 
chronic illness: a scoping literature review. BMC Public Health. 2012;12(1):1044. 
13. Soni A. Out-of-Pocket Expenditures for Adults with Health Care Expenses for Multiple 
Chronic Conditions, U.S. Civilian Noninstitutionalized Population. Statistical Brief (Medical 
Expenditure Panel Survey (US). Rockville (MD): Agency for Healthcare Research and 
Quality (US). 2017. STATISTICAL BRIEF #498. 
14. Lorgunpai SJ, Grammas M, Lee DSH, McAvay G, Charpentier P, Tinetti ME. Potential 
therapeutic competition in community-living older adults in the U.S.: Use of medications that 
may adversely affect a coexisting condition. PLoS ONE. 2014. 9(2): e89447. 
15. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st 
Century. Washington, D.C: National Academy Press; 2001. 
16. Tinetti ME, Naik AD, Dodson JA. Moving from disease-centered to patient goals–directed 
care for patients with multiple chronic conditions: Patient value-based care. JAMA Cardiol 
2016;1(1):9-10. 
17. Tinetti ME, Esterson J, Ferris R, Posner P, Blaum CS. Patient priority directed decision-
making and care for older adults with multiple chronic conditions. Clin Geriatr Med. 2016; 
32(2):261- 275. 
18. Ferris R, Blaum C, Kiwak E, et al. Perspectives of patients, clinicians, and health system 
leaders on changes needed to improve the health care and outcomes of older adults with 
multiple chronic condition. J Aging Health. 2018;20(5):778-799. 
19. Naik AD, Dindo L, Van Liew J, et al. Development of a clinically-feasible process for 
identifying patient health priorities. J Am Geriatr Soc. 2018; 66(10):1872-1879. 
20. Blaum C, Rosen J, Naik AD, et al. Feasibility of Implementing patient priorities-aligned care 
for patients with multiple chronic conditions. J Am Geriatr Soc. 2018; 66(10):2009-2016. 
21. Emily M. Mitchell. Concentration of Health Expenditures in the U.S. Civilian 
Noninstitutionalized Population, 2014. STATISTICAL BRIEF #497. 
22. Griffith LE, Gruneir A, Fisher K, Panjwani D, Gafni A, Patterson C, Markle-Reid M, Ploeg J. 
Insights on multimorbidity and associated health service use and costs from three population-
based studies of older adults in Ontario with diabetes, dementia and stroke. BMC Health Serv 
Res. 2019 May 16;19(1):313. doi: 10.1186/s12913-019-4149-3. 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
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Achieved through Primary and Specialty Care Alignment 
 
   
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23. Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalized care 
planning for adults with chronic or long‐term health conditions. Cochrane Database Syst 
Rev. 2015; (3):CD010523. 
24. Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients 
with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 
2016; 3: CD006560. 
25. Salisbury C, Man M-S, Bowers P, et al. Management of multimorbidity using a patient-
centered care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018; 
392 (10141): 41-50. 
26. Naik AD, Martin LA, Moye J, Karel MJ. Health values and treatment goals of older, 
multimorbid 
adults facing life‐threatening illness. J Am Geriatr Soc. 2016;64(3):625-631. 
27. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A framework for goals 
of care conversations. J Oncol Pract. 2017;13(10): e844-e850. 
28. Austin CA, Mohottige D, Sudore RL, Smith AK, Hanson LC. Tools to promote shared 
decision making in serious Illness: A systematic review. JAMA Intern Med. 
2015;175(7):1213-1222. 
29. Sudore RL, Knight SJ, McMahan RD, et al. A novel website to prepare diverse older adults 
for decision making and advance care planning: a pilot study. J Pain Symptom Manage. 
2014;47(4):674-686. 
30. Bernacki RE, Block SD. American College of Physicians High Value Care Task Force. 
Communication about serious illness care goals: a review and synthesis of best practices. 
JAMA Intern Med. 2014;174(12):1994-2003. 
31. MacKenzie MA, Smith-Howell E, Bomba PA, Meghani SH. Respecting Choices and Related 
Models of Advance Care Planning: A Systematic Review of Published Evidence. Am J Hosp 
Palliat Med. 2018; 35(6): 897–907. 
32. Naik AD, Palmer N, Petersen NJ, et al. Comparative effectiveness of goal setting in 
diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med. 
2011;171(5):453-459. 
33. Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalized care 
planning for adults with chronic or long‐term health conditions. Cochrane Database Syst 
Rev. 2015; (3):CD010523. 
34. Rockwood K, Stadnyk K, Carver D, et al. A clinimetric evaluation of specialized geriatric care 
for 
rural dwelling, frail older people. J Am Geriatr Soc. 2000;48(9):1080-1085. 
35. Toto PE, Skidmore ER, Terhorst L, Rosen J, Weiner DK. Goal Attainment Scaling (GAS) in 
geriatric 
primary care: a feasibility study. Arch Gerontol Geriatr. 2015;60(1):16-21. 
36. Tinetti ME, Naik AD, Dindo L, et al. Association of Patient Priorities–Aligned Decision-Making 
With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
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Chronic Conditions: A Nonrandomized Clinical Trial. JAMA Intern Med. 2019. 
doi:https://doi.org/10.1001/jamainternmed.2019.4235 
37.  Rosner, B. 2011. Fundamentals of Biostatistics, Seventh Edition. Brooks/Cole. Boston, MA. 
38.  Hsieh, F.Y., Block, D.A., and Larsen, M.D. 1998. 'A Simple Method of Sample Size Calculation 
for Linear and Logistic Regression', Statistics in Medicine, Volume 17, pages 1623-1634. 
39. Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental 
health summary scores from the patient-reported outcomes measurement information system 
(PROMIS) global items. Qual Life Res. 2009; 18(7): 873-880. 
40. Brandt Jason, Spencer Miriam, Folstein Marshal F. The Telephone Interview for 
Cognitive Status. Neuropsychiatry, Neuropsychology, and Behavioral 
Neurology. 1988;1:111–17. 
41. Forcino RC, Barr PJ, O’Malley AJ, et al. Using CollaboRATE, a brief patient- reported measure 
of shared decision making: Results from three clinical settings in the United States. Health 
Expect.2018;21(1):82–89. 
42. Tran VT, Harrington M, Montori VM, Barnes C, Wicks P, Ravaud P. Adaptation and validation 
of the Treatment Burden Questionnaire (TBQ) in English using an internet platform. BMC Med. 
2014;12:109. 
43. Bynum JPW, Meara ER, Chang CH, Rhoads JM, Bronner KK, Our parents, ourselves: Health 
care for an aging population. Lebanon, NH: The Dartmouth Institute of Health Policy and 
Clinical Practice, 2016. 
44. Tinetti ME, Naik AD, Dindo L, et al. Association of Patient Priorities–Aligned Decision-Making 
With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple 
Chronic Conditions: A Nonrandomized Clinical Trial. JAMA Intern Med. 2019. 
doi:https://doi.org/10.1001/jamainternmed.2019.4235 
 
 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Appendix.0 
 
Complete list of chronic conditions  
Acquired Hypothyroidism 
Acute Myocardial Infarction 
Alzheimer's Disease 
Alzheimer's Disease and Related Disorders or Senile Dementia 
Anemia 
Asthma 
Atrial Fibrillation 
Benign Prostatic Hyperplasia*  
Cataract 
Chronic Kidney Disease 
Chronic Obstructive Pulmonary Disease and Bronchiectasis 
Depression 
Diabetes 
Glaucoma 
Heart Failure 
Hip/Pelvic Fracture 
Hyperlipidemia 
Hypertension 
Ischemic Heart Disease 
Osteoporosis 
RA/OA (Rheumatoid Arthritis/ Osteoarthritis) 
Stroke / Transient Ischemic Attack** 
Female / Male Breast Cancer 
Colorectal Cancer 
Prostate Cancer 
Lung Cancer 
Endometrial Cancer 
 
 
 
 
 
 
 
 
 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Appendix 1. PPC components aligned with existing CCF roles 
 
PPC Priorities  
Facilitator’s 
key 
components 
 
Care Coordinator’s job description   
(excerpt from T99128 - Care 
Coordinator) 
 
 
Patient Liaison Program 
Coordinator’s job description  
(excerpt from D99797 - Patient 
Liaison Program Coordinator) 
 
Patient 
identification 
 
• 
Identifies which patients in the 
specialty care practice have 
ongoing care coordination 
needs for their specialty 
condition. 
 
• 
Utilizes technological tools 
(registries, patient lists, care 
team tab, etc.) to manage 
populations. 
 
 
 
• 
Proactively completes 
intentional rounding to 
meet new patients, 
promoting available 
programs and services. 
 
Patient priority 
assessment 
 
• 
Utilizes assessment skills and 
risk assessment tools to 
identify patients with actual or 
potential care needs that would 
require care coordination. 
 
• 
Conducts comprehensive 
clinical assessments that 
include disease-specific, age-
specific, medical, behavioral 
pharmacy, social and end of 
life needs of each patient. 
 
• 
Ensures care gaps are closed 
around specialty 
disease/chronic 
disease/surgical episodes. 
 
 
 
• 
Facilitates communication 
or responses to patient 
needs; ensures positive 
working relationship 
between physicians, 
employees, patients and 
families; supports highest 
quality of patient 
standards. 
 
• 
Identifies, evaluates, and 
resolves patient 
complaints. 
 
• 
Removes barriers to care, 
and facilitates 
coordination of care. 

IRB#20-555 Site PI: Ardeshir Hashmi                                                ClinicalTrials.gov identifier: NCT04510948 
Patient Priority Care for Older Adults with Multiple Chronic Conditions  
Achieved through Primary and Specialty Care Alignment 
 
   
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Collaboration 
with other 
specialty 
providers 
 
• 
Works collaboratively with 
interdisciplinary team to 
develop goals and plan 
interventions to maximize 
patient outcomes. 
 
• 
Partners with other care 
coordinator teams such as 
primary and transitional care 
social work, rehabilitation, 
pharmacy, palliative care and 
others 
 
 
 
• 
Works with other areas 
within the Institute and 
across the enterprise to 
implement services that 
meet the needs of the 
patient or the patient’s 
family. 
 
 
On-going 
patient support 
 
• 
Monitors patient compliance 
with plan of care. 
 
• 
Performs reassessments 
regarding patient progress 
toward goals and updates plan 
of care as appropriate. 
 
• 
Serves as primary patient 
contact for team related to 
condition/surgical episode and 
facilitates access to services. 
 
• 
Coordinates members of the 
patient care team. 
 
• 
Works with the patient and 
family to assess current 
knowledge, health literacy, and 
readiness to change, utilizing 
teach back to assess level of 
knowledge. 
 
 
 
• 
Provides education as 
needed. 
 
• 
Captures patterns of 
successes and challenges 
within the patient 
experience and enter into 
a data base to perform 
analysis that will drive 
improvements to patient 
services. 
 
• 
Involved in the 
implementation of new 
processes that will guide 
patients to the appropriate 
resources and support 
services they need to 
improve the patient 
experience.