ABSTRACT Introduction Individuals at risk for or living with multiple chronic conditions (MCC) require coordinated care that is often navigated across primary, specialty care, and community environments. Person‐centered care planning (PCCP) is an effective way to manage care for people with MCC needs but is not yet routine practice. Methods The PCCP for Persons with MCC Summit was the culminating event of 14‐months of three working groups and a series of environmental scans of PCCP approaches and models. The Summit convened participants from multiple sectors to address these questions of interest: (1) strategies to address and mitigate barriers to PCCP as an integral component of routine practice; (2) the development of actionable Learning Health System‐related steps for PCCP implementation; and (3) research priorities to advance PCCP for persons with MCC. Audio recordings, meeting transcripts and detailed notes were consolidated and reviewed to identify and synthesize key findings. Results The Summit was held March 2025 and attended by 84 in‐person and 31 online participants. Participants emphasized three key outcomes: improving the patient experience, strengthening the clinician‐patient relationship, and reducing care team burnout. Six interconnected themes relate to what needs to change to achieve PCCP: demand and awareness; quality measurement; team‐based care; technology; payment reform; and training. Strategies for change focused on short and long‐term goals, cross‐sector coordination, context, and community‐level interventions. Participants identified actionable implementation steps and six categories of research opportunities. Conclusions Widespread adoption of PCCP requires short‐ and long‐term efforts that raise awareness and investment, engage multi‐sector partners, and attend to context. Scaling PCCP as a widely used model of care for persons with or at risk of MCC will benefit from action from each partner in care. This transformational change could build upon evidence and Learning Health System strategies to advance research and inform organizational, payment and policy changes.
Davis et al. (Thu,) studied this question.