Personalized Health Planning (PHP) in Primary Care is one of three implementation modalities at the Durham VA Medical Center that was funded by the 2016-2018 Whole Health Design Site grant. PHP in Primary Care utilizes the Veteran Health Administration’s Patient Aligned Care Team (PACT) model to foster patient-centered primary care delivery.
The program introduced Veteran patients to the process of completing a Personal Health Inventory (PHI), a comprehensive analysis of health status and goals that includes: self-assessment of health status, Patient Activation Measure (PAM) ®, and personal SMART (Specific, Measurable, Action Oriented, Realistic, Timed) goals.
Together with their providers, patients then synthesized their priorities and goals with their provider’s health assessment to create shared SMART goals in a Personal Health Plan. A clinician then contacted the Veteran for follow-up approximately four weeks after their clinic visit to survey Veteran experience, goal progress, and recollect their PAM score. Information from the PHI, PHP, and follow-up was added into the patient’s EMR in efforts of care continuity.