“M” Is for Mutual

  • Alexander Blount


Transparency, empowerment, and activation can be supported by institutionalizing the mutual creation of the treatment plan that guides patients’ care in their primary care setting and in the health system more generally. The desire of patients to participate in creating the documentation of their care that emerged in the pilots of open notes can be addressed care through a process called a patient-centered care plan. A care plan is a brief distillation of the information that is needed to inform a successful treatment. For multiply-disadvantaged patients, who are likely to have a history of difficult experiences in the healthcare system, knowledge of the patients’ hopes about the ways that their health teams should relate to them, when shared with any internal or extended team member, can help to keep partnership intact through difficult or upsetting times. When done well, multiple members of the team are involved in creating a document that reflects the patients’ ideas and values on which a successful relationship would be built. The creation and utilization of the PCCP become a crucial experience in building partnership for both patients and health professionals.


Complex patients Patient-centered Care plans Patient participation Patient empowerment Team-based care Healthcare reform 


  1. 1.
    Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and look ahead. Ann Intern Med. 2012;157:461–70.CrossRefGoogle Scholar
  2. 2.
    Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, Cannuscio CC. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16:S26–33.CrossRefGoogle Scholar
  3. 3.
    Medical Dictionary for the Health Professions and Nursing. 2012. Retrieved 2018, August 22 from
  4. 4.
    American Academy of Pediatrics. Care plan. Retrieved 2018.
  5. 5.
    Chunchu K, Mauksch L, Charles C, Ross V, Pauwels J. A patient centered care plan in the EHR: improving collaboration and engagement. Fam Syst Health. 2012;30:199–209.CrossRefGoogle Scholar
  6. 6.
    Patient Centered Primary Care Institute. The shared care plan of Whatcom County, Washington, slides 17–24; 2013. Accessed 20 Aug 2018.Google Scholar
  7. 7.
    Safford B. Conversation with Bertha Safford, MD, 8/20/18. 2018.Google Scholar
  8. 8.
    Council LS, Geffken D, Valeras AB, et al. A medical home: changing the way patients and teams relate through patient-centered care plans. Fam Syst Health. 2012;30:190–8.CrossRefGoogle Scholar
  9. 9.
    Morse J, Valeras A, Geffken D, Eubank D, Orzano AJ, Dreffer D, DeCook A, Valeras AB. Using a team approach to address avoidable emergency department utilization and rehospitalizations as symptoms of complexity through quality improvement. In: Sturmberg JP, editor. The value of systems and complexity science for healthcare. New York: Springer; 2016.Google Scholar
  10. 10.
    Kahtri P, Gunn W, Talan M, Valeras A, Peek CJ. Beyond hotspotting: identifying complexity and solutions at the micro, meso, and macro levels. Presented at the collaborative family healthcare conference, Rochester, NY. 2018.Google Scholar
  11. 11.
    Oxman TE, Hegel MT, Hull JG, Dietrich AJ. Problem-solving and coping styles in primary care for minor depression. J Consult Clin Psychol. 2008;76:933–43.CrossRefGoogle Scholar
  12. 12.
    Mold J, Hamm R, Scheid D. Evidence- based medicine meets goal-directed health care. Fam Med. 2003;35:360–4.PubMedGoogle Scholar
  13. 13.
    Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209–14.CrossRefGoogle Scholar
  14. 14.
    Rosal MC, Ockene JK, Luckmann R, et al. Coronary health disease multiple risk factor reduction. Providers’ perspectives. Am J Prev Med. 2004;27(Suppl. 2):54–60.CrossRefGoogle Scholar
  15. 15.
    Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5:457–61.CrossRefGoogle Scholar
  16. 16.
    Mauksch L. Personal communication. 2013.Google Scholar
  17. 17.
    Dixon A, Hibbard J, Tusler M. How do people with different levels of activation self-manage their chronic conditions? Patient. 2009;2:257–68.CrossRefGoogle Scholar
  18. 18.
    Ross J. Care plans best practices for development and implementation. Patient Centered Primary Care Institute, Portland, OR, slides 33–39; 2013. Accessed 2 Aug 2018.Google Scholar
  19. 19.
    Ross J. Conversation with Jackie Ross, 8/28/18. 2018.Google Scholar
  20. 20.
    Chait S. Conversation with Sari Chait, 8/28/18. 2018.Google Scholar
  21. 21.
    Leppin AL, Montori VM, Gionfriddo MR. Minimally disruptive medicine: A pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare. 2015;3:50–63.CrossRefGoogle Scholar


    Developing a Care Plan for Complex Patients

    1. Examples of Shared Care Plans – PCPCI – Patient Centered Primary Care Institute, Portland, OR
    2. Whatcom County Shared Care Plan – Institute for Healthcare Improvement

    Setting Goals

    1. Setting Goals with People with Complex Needs: A Collaborative Approach. National Committee for Quality Assurance.
    2. Goals to Care: How to keep the person in “person-centered”. National Committee for Quality Improvement.

    Setting Goals, Care Management, Staff Training

    1. The COACH Model of the Camden Coalition.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Alexander Blount
    • 1
  1. 1.Department of Clinical PsychologyAntioch University New EnglandKeeneUSA

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