Aligning Care with the Personal Values of Patients with Complex Care Needs

Leah Tuzzio
Andrew L. Berry
Kathy Gleason
Jennifer Barrow
Elizabeth A. Bayliss
Marlaine Figueroa Gray
Thomas Delate
Zoe Bermet
Connie S. Uratsu
Richard W. Grant
James D. Ralston
Peer-Reviewed Article
August 2021


Understanding the values of patients with complex health and social needs can help providers improve care.


Interventions focused on improving health and cost outcomes for people with complex health and social needs have shown mixed results, potentially due to ineffective intervention design and evaluation and/or misunderstanding of patient values, priorities, and goals of care. For complex care programs to succeed, health care providers should learn what patients with complex needs view as most important for their health and well-being. This qualitative study details strategies for improving care for people with complex needs informed by interviews with 24 patients from Kaiser Permanente Washington and Kaiser Permanente Colorado. The study participants represent three distinct high-need patient profiles: (1) people with obesity and an opioid prescription from low-resourced neighborhoods; (2) older adults with multiple chronic conditions and frequent acute care use; and (3) older adults with mental and physical health concerns from low-resourced neighborhoods.


All three groups shared what they felt would be most important to support their health and values. Potential opportunities for aligning care with patients’ personal values were organized into the following themes:

  1. Acknowledging patient values and providing care that supports these values;
  2. Providing access to non-physician providers who have different care delivery methods, such as nurses, chiropractors, dietitians, acupuncturists, and counselors;
  3. Offering mental health support;
  4. Connecting patients to community-based social resources that align with personal values, such as transportation to church or volunteering; and
  5. Supporting families and caregivers.


Although all patients interviewed wanted similar supports, not everyone had the same needs, so this study drives home the importance of individualizing care for people with complex needs. Uncovering patients’ values, health-related social needs, and functional challenges can help providers give patients the best tailored care.

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