Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions

With the aging of the population and continuing advances in health care, patients seen in the primary care setting are increasingly complex. At the same time, the number of screening and chronic condition management tasks primary care providers are expected to cover during brief primary care office visits has continued to grow. These converging trends mean that there is often not enough time during each visit to address all of the patient's concerns and needs, a significant barrier to effectively providing patient-centered care. For complex patients, prioritization of which issues to address during a given visit must precede discrete decisions about disease-specific treatment preferences and goals. Negotiating this process of setting priorities represents a major challenge for patient-centered primary care, as patient and provider priorities may not always be aligned. In this review, we present a synthesis of recent research on how patients and providers negotiate the visit process and describe a conceptual model to guide innovative approaches to more effective primary care visits for complex patients based on defining visit priorities. The goal of this model is to inform interventions that maximize the value of available time during the primary care encounter by facilitating communication between a prepared patient who has had time before the visit to identify his/her priorities and an informed provider who is aware of the patient's care priorities at the beginning of the visit. We conclude with a discussion of key questions that should guide future research and intervention development in this area.