{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T11:00:43Z","timestamp":1790852443419,"version":"4.1.0"},"reference-count":17,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["75Q80120D00019\/75Q80124F32002"],"award-info":[{"award-number":["75Q80120D00019\/75Q80124F32002"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Learning Health Systems"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Persons with multiple chronic conditions often receive care from a complicated network of multiple providers across multiple health systems unique to their conditions, needs, available resources, and insurance. Patients must navigate this healthcare system, which is a difficult and complicated process with just one provider or system, let alone multiple. Developing new solutions to overcome the systemic challenges within healthcare systems to provide high\u2010quality, comprehensive, person\u2010centered care for persons living with, or at risk for, multiple chronic conditions is critical. Person\u2010centered care is needed, not only because it is the right and just approach to supporting patients, but because of the profound implications of the increasing prevalence of multiple chronic conditions on healthcare costs, caregiver burden, workforce productivity, and the broader social fabric. In this commentary, we present patient perspectives on a project that brought together diverse groups to identify potential solutions to challenges in implementation of person\u2010centered care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Patients, families, and family caregivers are essential to the design and implementation of person\u2010centered care planning for people with multiple chronic conditions. The Agency for Healthcare Research and Quality (AHRQ) funded a project aimed at compiling best practices and discussing barriers. The project used a learning system approach to engage policy experts, clinicians, researchers, and persons with multiple chronic conditions, their families, and family caregivers. Four main activities included a technical expert panel, an environmental scan, a partner roundtable, and a learning collaborative. An in\u2010person\/hybrid summit held in March 2025 summarized activities and provided a forum for presentations to share activities of the project and conduct small group discussions on select topics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results\/Framework<\/jats:title>\n                    <jats:p>We present patient narratives to complement content provided by the partner roundtables and other AHRQ\u2010funded activities that provided foundational knowledge and diverse perspectives to promote person\u2010centered care planning as standard practice for persons with multiple chronic conditions. Although many challenges to implementation of person\u2010centered care were identified and discussed, learning from successful models and customization of models using components as appropriate may help overcome barriers. In particular, the need for culture change, use of meaningful measures, scalability, and other concepts must be addressed. Alignment of payment structures and policy support will be essential to ensuring that person\u2010centered care can be advanced as an integral component of routine care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion\/Next Steps<\/jats:title>\n                    <jats:p>Multiple challenges to adoption of person\u2010centered care planning have been identified. Future work by multidisciplinary teams (that must include patients, caregivers, policymakers, and clinicians) is needed to develop evidence\u2010based feasible solutions to overcome these barriers in ways that respect the values and preferences of patients, families, and caregivers.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/lrh2.70122","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T10:52:58Z","timestamp":1790851978000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Moving Person\u2010Centered Care Planning From Theory Into Practice: Patient Perspectives"],"prefix":"10.1002","volume":"10","author":[{"given":"Claire","family":"Sachs","sequence":"first","affiliation":[{"name":"TPAC Consulting and The Patient Advocate's Chronicle  Washington DC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-8258-9412","authenticated-orcid":false,"given":"Mary F.","family":"Henningfield","sequence":"additional","affiliation":[{"name":"Wisconsin Research and Education Network, Department of Family Medicine and Community Health University of Wisconsin\u2013Madison  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1133-5589","authenticated-orcid":false,"given":"Sarina","family":"Schrager","sequence":"additional","affiliation":[{"name":"Wisconsin Research and Education Network, Department of Family Medicine and Community Health University of Wisconsin\u2013Madison  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-2507-1057","authenticated-orcid":false,"given":"Meagan","family":"Sulikowski","sequence":"additional","affiliation":[{"name":"Wisconsin Research and Education Network, Department of Family Medicine and Community Health University of Wisconsin\u2013Madison  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle","family":"Robinson","sequence":"additional","affiliation":[{"name":"The Foundation for Black Women's Wellness  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"key":"e_1_2_14_2_1","unstructured":"US Centers for Disease Control and Prevention \u201cTrends in Multiple Chronic Conditions Among US Adults by Life Stage Behavioral Risk Factor Surveillance System 2013\u20132023 \u201dCDC published April 17 2025 https:\/\/www.cdc.gov\/pcd\/issues\/2025\/24_0539.htm."},{"key":"e_1_2_14_3_1","doi-asserted-by":"crossref","DOI":"10.3389\/fpubh.2022.1082183","article-title":"Projecting the Chronic Disease Burden Among the Adult Population in the United States Using a Multi\u2010State Population Model","volume":"10","author":"Ansah J. P.","year":"2023","journal-title":"Frontiers in Public Health"},{"key":"e_1_2_14_4_1","unstructured":"Centers for Medicare & Medicaid Service \u201cPerson\u2010Centered Care \u201dCMS published August 14 2023 https:\/\/www.cms.gov\/priorities\/innovation\/key\u2010concepts\/person\u2010centered\u2010care."},{"issue":"2","key":"e_1_2_14_5_1","doi-asserted-by":"crossref","DOI":"10.1136\/bmjdrc-2020-001926","article-title":"Person\u2010Centered Diabetes Care and Patient Activation in People With Type 2 Diabetes","volume":"8","author":"Rutten G. E. H. M.","year":"2020","journal-title":"BMJ Open Diabetes Research & Care"},{"issue":"5","key":"e_1_2_14_6_1","doi-asserted-by":"crossref","first-page":"305","DOI":"10.2337\/cd17-0029","article-title":"Improving Diabetes Self\u2010Management Support: Goal\u2010Setting Across the Continuum of Care","volume":"35","author":"Klinkner G. E.","year":"2017","journal-title":"Clinical Diabetes"},{"issue":"1","key":"e_1_2_14_7_1","doi-asserted-by":"crossref","first-page":"50","DOI":"10.3390\/healthcare3010050","article-title":"Minimally Disruptive Medicine: A Pragmatically Comprehensive Model for Delivering Care to Patients With Multiple Chronic Conditions","volume":"3","author":"Leppin A. L.","year":"2015","journal-title":"Healthcare"},{"key":"e_1_2_14_8_1","unstructured":"M.Cullom \u201cRequest for Information on Person\u2010Centered Care Planning for Multiple Chronic Conditions (MCC) \u201dAgency for Healthcare Research and Quality published September 12 2022 https:\/\/www.federalregister.gov\/d\/2022\u201020027."},{"issue":"2","key":"e_1_2_14_9_1","doi-asserted-by":"crossref","DOI":"10.1002\/lrh2.70073","article-title":"Person\u2010Centered Care Planning for Persons With Multiple Chronic Conditions: Summary of an Agency for Health Care Research and Quality Sponsored Summit","volume":"10","author":"Davis M. M.","year":"2026","journal-title":"Learning Health Systems"},{"key":"e_1_2_14_10_1","unstructured":"Agency for Healthcare Research and Quality \u201cAdvancing Patient\u2010Centered Care for People Living With Multiple Chronic Conditions \u201dAHRQ September 2025 https:\/\/www.ahrq.gov\/patient\u2010safety\/settings\/long\u2010term\u2010care\/resource\/multichronic\/mcc.html."},{"key":"e_1_2_14_11_1","unstructured":"A. R.Qui\u00f1ones L. C.Michaels J.Coury K. D.Peak M. M.Davis andD. A.Dorr Person Centered Care Planning for Persons With Multiple Chronic Conditions: Summit Summary Report (Prepared Under Contract No. 75Q80120D00019\/75Q80124F32002)(Agency for Healthcare Research and Quality 2025) https:\/\/www.ahrq.gov\/sites\/default\/files\/wysiwyg\/mcc\/pccp4p\/pccp4p\u2010summitsummary.pdf."},{"key":"e_1_2_14_12_1","unstructured":"A. M.Totten C.Davis\u2010O'Reilly C.Atchison et\u00a0al. Person Centered Care Planning for Persons With Multiple Chronic Conditions: Current Approaches and Models Used in Health Care Settings in the United States (Prepared under Contract No. 75Q80120D00019\/75Q80124F32002)(Agency for Healthcare Research and Quality 2025) https:\/\/www.ahrq.gov\/sites\/default\/files\/wysiwyg\/mcc\/pccp4p\/baseline\u2010scan\u2010report.pdf."},{"key":"e_1_2_14_13_1","volume-title":"Person\u2010Centered Care Planning for Persons With Multiple Chronic Conditions: Partner Roundtable Synthesis","author":"Schrager S.","year":"2025"},{"key":"e_1_2_14_14_1","unstructured":"L.Anderson L. C.Michaels K. D.Peak E.De Marchis andD. A.Dorr Person\u2010Centered Care Planning for Persons With Multiple Chronic Conditions: Learning Collaborative Report. (Prepared under Contract No. 75Q80120D00019\/75Q801 24F32002)(Agency for Healthcare Research and Quality 2025) https:\/\/www.ahrq.gov\/sites\/default\/files\/wysiwyg\/mcc\/pccp4p\/pccp4p\u2010learningcollab.pdf."},{"key":"e_1_2_14_15_1","volume-title":"StatPearls","author":"Shah S. J.","year":"2025"},{"key":"e_1_2_14_16_1","unstructured":"C.Tucker \u201cWhy Patients Struggle to Follow Care Plans\u2014and How Practices Can Support Better Follow\u2010Through \u201dRXNT February 2 2026 https:\/\/www.rxnt.com\/why\u2010patients\u2010struggle\u2010to\u2010follow\u2010care\u2010plans\u2010and\u2010how\u2010practices\u2010can\u2010support\u2010better\u2010follow\u2010through\/."},{"issue":"3","key":"e_1_2_14_17_1","first-page":"163","article-title":"Patients' Lived Experiences of the Paternalistic Care Behavior: A Qualitative Study","volume":"11","author":"Pourgholam N.","year":"2022","journal-title":"Journal of Caring Sciences"},{"key":"e_1_2_14_18_1","doi-asserted-by":"publisher","DOI":"10.1002\/lrh2.70101"}],"container-title":["Learning Health Systems"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/lrh2.70122","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/lrh2.70122","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/lrh2.70122","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T10:53:03Z","timestamp":1790851983000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/lrh2.70122"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10]]},"references-count":17,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,10]]}},"alternative-id":["10.1002\/lrh2.70122"],"URL":"https:\/\/doi.org\/10.1002\/lrh2.70122","archive":["Portico"],"relation":{},"ISSN":["2379-6146","2379-6146"],"issn-type":[{"value":"2379-6146","type":"print"},{"value":"2379-6146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10]]},"assertion":[{"value":"2025-09-05","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-09-17","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-10-01","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70122"}}