Patient-centered plan-of-care tool for improving clinical outcomes.

Purpose: In developing our Patient-Centered Team Care (PCTC) program, we designed a Plan-of-Care (POC) tool to facilitate the physician-patient discussion for setting health goals. This study aimed to determine the effectiveness of the POC tool in improving clinical outcomes.

Methods: We compared baseline and 6-month or greater follow-up values for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SP), diastolic blood pressure (DP), and weight for PCTC patients (intervention group) and non-PCTC patients (control group).