Enhancing Patient Empowerment and Adherence Through a Visit Care Management Worksheet

Abstract

Background: Chronic conditions affect over 60% of United States (US) adults, with 40% managing two or more. Among Medicare beneficiaries, 80% have multiple chronic conditions creating significant care burdens for patients, caregivers, and providers (Bierman et al., 2021; Campbell et al., 2021). Older adults in rural Arizona face additional challenges, including provider shortages, limited access to technology, health literacy barriers, and fragmented communication across care settings. Many rely on memory or fragmented notes rather than structured visit summaries, contributing to poor adherence and outcomes. Evidence supports that patient-centered visit tools improve recall, engagement, and self-management (Garfield et al., 2020; Nafradi et al., 2017). Purpose: This project aimed to enhance patient empowerment and self-management for patients aged 65 and older with two or more chronic conditions in rural Arizona by utilizing in-visit care worksheets completed collaboratively with the patient. Methods: Guided by the Plan-Do-Study-Act (PDSA) framework, the project was implemented at a federally qualified health center. Eligible patients (n = 12) participated in visits where providers used a structured worksheet to reinforce treatment plans, facilitate medication reconciliation, and outline next steps. Post-visit surveys, adapted from the Chinese Empowerment Survey, assessed empowerment, engagement, and adherence intention using a 5-point Likert scale and a free-text feedback portion. Results: Patients reported high levels of empowerment and engagement, with mean scores of responses ranging from 4.5 to 4.9 across the domains of confidence, understanding, communication, and ownership of care. Ninety-two percent of participants expressed interest in using the worksheet for future visits. Free-text feedback indicated strong satisfaction with minimal suggested changes. Conclusions: This visit care management worksheet enhanced patient empowerment, communication, and preparedness while requiring minimal resources. Findings suggest this low-cost, evidence-based tool is feasible and sustainable for improving chronic disease management in rural older adults and could be scaled across primary care settings to strengthen patient-provider partnerships and advance health equity.