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Patient-Centered Care Explained: 7 Examples for Healthcare Leaders

Key takeaways:

• Patient-centered care is a framework that places a patient's values, preferences, and goals at the center of every clinical decision.
• Brief, rushed appointments leave a gap in communication between visits where chronic conditions worsen and patients lose track of their care plans.
• To successfully deliver patient-centered care, practices must embed core principles, such as emotional support and SDOH screenings, into everyday workflows.
• Patient-centered care and value-based care are complementary, not competing, and strong performance in one tends to support the other.
• Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) allow practices to operationally and financially sustain the outreach needed for patient-centered care.

Patient-centered care is a structured model for delivering healthcare, not a loosely defined philosophy. Most healthcare leaders aren’t questioning whether it’s effective but rather how to deliver it consistently, given limited staff capacity and time.

A 15-minute visit leaves little room to address a patient's full picture of health. A PartnerMD survey of over 500 respondents found that 68 percent of patients say their primary care appointments feel rushed. Most practices lack processes for patient outreach during the time between appointments. For patients managing chronic conditions, that gap is where disease progression accelerates, medications lapse, and care plans go unreviewed.

Closing that gap requires dedicated processes for reaching patients consistently between visits. For practices evaluating how to operationalize this work without adding strain to internal staff, ChartSpan’s Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) programs provide fully managed support for enrollment, outreach, documentation, compliance, and billing.

In this article, we explain what patient-centered care means, outline its core principles, walk through concrete examples of how it functions in practice, and examine how CCM and APCM help practices deliver care personalized to each patient’s needs.

What is patient-centered care?

Patient-centered care is a model of healthcare delivery that places the patient's values, preferences, and goals at the center of every clinical decision. Rather than organizing care around a diagnosis or a provider's clinical judgment alone, this model treats patients and their families as active participants whose priorities shape the direction of treatment.

The model developed as a direct response to episodic, provider-driven care: a system built around conditions and encounters rather than individuals and continuity. In that model, a patient with type 2 diabetes, hypertension, and chronic kidney disease might see three separate specialists who each manage their piece of the picture without communicating across it. 

Patient-centered care reorients that model so the whole person, not just the presenting condition, guides the care team's work.

The Picker Institute’s 8 principles of patient-centered care

The Picker Institute identified eight principles that define what person-centered care requires in practice. While person-centered care extends beyond the patient to the staff and systems that support their care, these principles also describe what the patient-centered experience needs to include:

• Respect for patients' values, preferences, and needs: Care decisions reflect what matters to the patient, including their cultural background, personal priorities, and stated goals, not just clinical best practices in isolation.
• Coordination and integration of care: Providers, specialists, and care team members work together so the patient experiences cohesive care rather than disconnected encounters.
• Clear information, communication, and education: Patients receive clear, timely information about their conditions, treatment options, and next steps, in a format and language they can act on.
• Physical comfort: Pain management, symptom monitoring, and attention to physical well-being are treated as core components of care, not secondary concerns.
• Emotional support: Anxiety, fear, and the psychological weight of managing a chronic illness are acknowledged and addressed as part of the care relationship.
• Involvement of family and friends: Caregivers and family members are included in care discussions and planning when the patient chooses, recognizing the role they play in health outcomes.
• Care continuity and transitions: Patients receive consistent support as they move between providers, care settings, or phases of treatment, with clear communication at every handoff.
• Fast and reliable access to care: Patients can reach the care they need, when they need it, without barriers related to scheduling, referrals, transportation, language, or health literacy.

7 examples of patient-centered care in action

Principles only produce outcomes when they are embedded into specific workflows and touchpoints. Below are seven examples of what these principles look like in practice, particularly between visits, where most practices have the least structure and the greatest opportunity to address gaps in care continuity.

1. Create individualized wellness plans

Patient-centered care begins with a care plan built around the individual, not a condition-specific protocol applied uniformly. A meaningful care plan documents the patient's active chronic conditions, current medications, relevant social context, personal health goals, and any barriers to following through on treatment. It functions as a living document, updated as the patient's circumstances change rather than completed once and filed.

Without a documented, individualized plan, care coordination defaults to reactive problem-solving rather than proactive management. Both Chronic Care Management and Advanced Primary Care Management require a comprehensive, patient-centered care plan as a core program element.

2. Elevate patient agency through collaborative goal-setting

Patients who participate in setting their own health goals are more likely to follow through on them. Collaborative goal-setting is a clinical practice that has measurable effects on adherence and self-management.

In practice, this means a care manager and patient working together to define specific, realistic objectives. For a patient managing COPD and heart failure, that might include a target for daily activity, a threshold for when to call before symptoms escalate, or a plan for managing medication refills consistently. The care manager documents the agreed-upon goals, reviews progress at regular intervals, and adjusts as the patient's condition or priorities evolve.

3. Offer 24/7 inbound access and proactive outreach

Access to care should extend beyond appointment availability. A patient who develops a concern at 9 p.m. on a Thursday needs a way to reach someone before that concern becomes an emergency department visit. Both CCM and APCM require 24/7 access to care as a core program element.

Proactive outbound outreach matters equally. Regular check-ins from a care manager give patients a consistent point of contact, surface issues before they escalate, and reinforce that someone is monitoring their care between visits. The combination of inbound availability and outbound engagement is necessary for true access to care.

4. Provide continuous emotional and clinical support

Chronic disease management carries a psychological dimension that a routine visit rarely has the capacity to address. Patients managing multiple long-term conditions often experience anxiety, isolation, and fatigue alongside their physical symptoms. Visit-based care can address clinical markers without ever reaching the emotional effects of living with a chronic illness.

Regular contact from a dedicated care manager provides both clinical monitoring and emotional continuity. A patient who hears from the same care manager each month develops a relationship built on familiarity and trust, not just a transactional check on lab values. That consistency supports engagement and helps patients maintain adherence to their care plans during difficult periods.

5. Coordinate care transitions to prevent gaps in coverage

Care transitions are some of the highest-risk moments in a patient's care journey. Hospital discharge, specialist referrals, and setting changes all create opportunities for information to be lost, medications to lapse, and follow-up to fall through.

Transition support includes timely post-discharge outreach, medication reconciliation to confirm the patient's regimen is accurate and accessible, and clear communication between the discharging facility and the primary care team. A peer-reviewed study found that care transition teams using SDOH screening reduced 30-day readmission rates from 18% to 9%.

Because of the documented risk that unmanaged transitions carry for patients with complex needs, APCM specifically requires post-discharge follow-up as a service element. Care managers follow up with patients shortly after their discharge to ensure they understand their care plan and new medications, can get those medications refilled or delivered, have transportation to their upcoming appointments, and have an upcoming appointment with their primary care provider post-discharge. If patients are struggling with any of these elements, care managers can provide community resources, send educational materials, or assist them with medication refills and appointment scheduling. 

6. Connect patients with essential community and SDOH resources

Social Determinants of Health (SDOH), including transportation access, food security, housing stability, and medication affordability, directly affect whether patients can follow through on their care plans. A CDC-authored study of over 324,000 adults found that nearly 60 percent of those with chronic diseases report one or more adverse SDOH. A patient who cannot afford their medications or get a ride to a specialist appointment will not benefit from an otherwise well-designed care plan.

Care managers screen for social needs and connect patients to relevant community resources, from medication assistance programs to local transportation services. This function also includes providing educational materials written at appropriate reading levels and offering care management in multiple languages, both of which are essential for reaching patients who face health literacy or language barriers to care.

7. Facilitate information sharing across the care journey

Every member of the care team needs an accurate, current picture of the patient's health to make informed decisions. When care plans are outdated, documentation is incomplete, or providers are working from different versions of the patient's record, the risk of misaligned treatment increases.

Effective information sharing requires updated care plans, consistent documentation practices, and communication across providers and settings. CCM and APCM both embed documentation requirements into their program structure, creating a framework that supports continuity. The electronic health record (EHR) serves as the central reference point, but only when the information in it is maintained with the same rigor applied to clinical care itself.

Patient-centered care vs. value-based care

Patient-centered care and value-based care are frequently referenced together, but they describe different dimensions of healthcare delivery. Understanding the distinction matters for healthcare leaders evaluating both how to care for patients and how their performance will be measured and reimbursed.

• Patient-centered care describes how care is delivered: with the patient's preferences, goals, and values guiding clinical decisions.
• Value-based care describes how care is reimbursed: based on outcomes and quality rather than the volume of services provided.

These are complementary rather than competing frameworks. Practices that consistently deliver patient-centered care may perform better on the quality metrics that drive value-based reimbursement, including chronic disease control, preventive care completion, hospital readmission rates, and patient engagement. Patient-centered care is not a prerequisite for value-based participation, but it is one of the more reliable paths to the outcomes those contracts reward.

Programs like CCM and APCM put that alignment into practice. Both require a documented care plan, consistent communication, and coordinated outreach—the same elements that define patient-centered care—while also supporting the quality and cost outcomes value-based contracts are built around.

	Patient-centered care	Value-based care
Focus	How care is delivered	How care is reimbursed
Measurement	Patient experience, goal attainment, care continuity	Quality metrics, outcomes, cost efficiency
Reimbursement structure	Not directly tied to a payment model	Tied to performance on defined quality measures
Primary goal	Align care with individual patient preferences and needs	Improve population health outcomes while managing cost

How CCM and APCM deliver patient-centered care between visits

Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) are the frameworks CMS built to fund and support the between-visit care that patient-centered principles require. For many practices, these programs represent the clearest path from patient-centered intent to patient-centered execution.

CCM: structured support for patients with chronic conditions

CCM is designed for Medicare patients with two or more chronic conditions. The program supports three core patient-centered elements, each addressing a different piece of care that a routine visit can't sustain on its own:

• Monthly outreach from qualified clinical staff creates a consistent touchpoint for emotional support and clinical monitoring.
• Comprehensive care plan management ensures documentation reflects the individual patient rather than a generic protocol.
• 24/7 care lines provide access to support anytime patients have questions or concerns between appointments.

For organizations that want to offer these services without building the entire program internally, ChartSpan’s Chronic Care Management program includes patient identification, enrollment, monthly engagement, care coordination, documentation support, and billing workflow management. This kind of operational support can help you maintain compliance while extending coordinated, patient-centered care across a growing chronic care population.

APCM: expanding patient-centered care across the Medicare population

Unlike CCM, APCM isn't limited to patients with two or more chronic conditions: it extends the same care management approach across a broader Medicare population.

The program requires several continuously available service elements, including a patient-centered care plan, 24/7 access to care, post-discharge follow-up, care coordination, Social Determinants of Health (SDOH) screening, and ongoing patient engagement. This structure makes APCM a practical framework for practices that want to extend patient-centered care to a wider segment of their Medicare panel without building a separate workflow for each patient tier.

For primary care organizations, a managed APCM model can reduce the administrative lift associated with stratification, enrollment, outreach, quality measurement, and billing. ChartSpan’s Advanced Primary Care Management program is designed to support those workflows while helping practices maintain continuity of care across their Medicare population.

Putting patient-centered principles into action

Without a program supporting between-visit care, patient-centered principles remain difficult to sustain at scale. A practice committed to patient-centered care still needs the staff, workflows, and documentation infrastructure to deliver on that commitment consistently. CCM and APCM provide that support, and CMS reimburses for it, creating a model where patient-centered care and financial sustainability reinforce each other rather than compete.

Deliver a patient-centered standard of care with ChartSpan

Consistent, individualized care between visits takes staff time most practices don't have to spare. CCM and APCM give practices a way to provide that outreach, documentation, and coordination without pulling clinical teams away from the patients in front of them.

ChartSpan offers fully managed CCM and APCM programs, providing dedicated care managers, proactive outreach, 24/7 inbound care line access, SDOH screening and navigation, multilingual care management, and compliant documentation that meet program requirements without adding significant operational weight to your staff. As your practice connects with patients and cares for them during in-office visits, ChartSpan supports the continuity that makes those relationships meaningful over time.

Whether your priority is supporting Medicare patients with multiple chronic conditions through Chronic Care Management or expanding preventive, longitudinal support across a broader Medicare panel through Advanced Primary Care Management, a successful care management program requires sustained patient engagement, coordinated workflows, and documentation that aligns with CMS requirements.

Talk to an expert to see what a fully managed CCM or APCM partnership could look like for your practice.

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