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Principles of Patient-Centered Care & How They Strengthen Value-Based Care Performance

Healthcare leaders are being asked to do two things at once: improve outcomes and manage costs under value-based care (VBC), while also delivering patient-centered care that reflects what matters to patients and supports their active participation in their health. Those goals should align, yet in practice, they often feel disconnected.

Many VBC programs rely on system-centric measures, like clinical targets, process measures, and utilization benchmarks, rather than metrics that reflect patient experience, preferences, or participation in care decisions. Without a patient-centered lens in measurement, it becomes difficult to know whether VBC initiatives are advancing patient-centered care or merely optimizing contract performance.

Another challenge is operational. Patient-centered care is built on empathy, shared decision-making, holistic understanding, and coordinated support, but these require time, continuity, and relationship-building. Most organizations believe in PCC but struggle to deliver it consistently between visits, where most barriers, decisions, and adherence issues occur.

But when PCC principles are practiced reliably, patients engage more fully, manage chronic conditions more effectively, and rely less on avoidable emergency or inpatient care—the very outcomes VBC is designed to reward. The issue isn’t whether PCC works, but how to deliver it at scale.

Care management programs such as Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) help bridge both gaps. They provide structured touchpoints, relational continuity, and real-world support that make PCC repeatable across a population, while also generating the patient-centered insights organizations need to connect daily experience with measurable value-based performance.

Patient-centered care defined

At its core, patient-centered care is an approach to care that treats the patient as a unique individual rather than a diagnosis. It involves:

Respecting the patient as a person, not just a “case” or “condition.”
Considering the patient’s standpoint, daily realities, and circumstances when making decisions, not simply presenting a plan and asking for compliance.
Basing communication, interaction, and shared decision-making on the patient’s informed wishes and preferences.

The philosophical foundation for modern patient-centered care stems from Engel’s biopsychosocial model, which shifted healthcare away from a purely biomedical view toward one that recognizes the interplay of biological, psychological, and social factors. This model reframed health as something shaped by a person’s lived context, not just by disease.

Patient-centered vs. person-centered care

Patient-centered and person-centered care are often used interchangeably, and neither has a universally accepted definition, but the differences become meaningful when you’re trying to operationalize patient-centered care in a value-based environment.

Similarities

Both philosophies view patients as active participants rather than passive recipients of care. They emphasize seeing the individual behind the symptoms, understanding their broader context, and shaping care through collaboration rather than directive instruction. One thematic analysis found that both forms of care share nine core principles: empathy, respect, engagement, relationship-building, communication, shared decision-making, holistic focus, individualized focus, and coordinated care.

Whether labeled “patient-centered” or “person-centered,” both approaches aim to build care around the individual’s needs, preferences, and perspectives.

Distinctions

Despite these shared foundations, the two approaches diverge in purpose and scope in ways that matter for how organizations operationalize them.

Goals

Person-centered care focuses on supporting a meaningful life, one that reflects a person’s identity, values, and relationships, beyond the boundaries of illness. Patient-centered care, by contrast, focuses on supporting a functional life, helping individuals understand and manage disease, maintain stability, and achieve better health outcomes.

Both goals are important, but they represent different layers of emphasis. Person-centered care begins with the individual’s identity, relationships, and life context. Patient-centered care begins with the illness but grounds treatment decisions in the patient’s values and circumstances.

Scope of care
Person-centered care extends well beyond the clinic. It considers the full context of a person’s everyday life, including family, history, strengths, social supports, and the environments that shape their wellbeing, and often involves multidisciplinary networks and community resources.

In contrast, patient-centered care remains rooted in the clinical setting. It is holistic, but its focus is on supporting health, treatment decisions, and functional outcomes within the healthcare environment.

Choosing a framework for VBC performance

Patient-centered care aligns most closely with the operational and measurable aspects of VBC, such as clinical workflows, chronic disease management, and quality metrics.

Even so, insights from person-centered care remain vital. Its focus on context, relationships, and lived experience strengthens the very same engagement behaviors that PCC seeks to build.

Care-management programs like CCM and APCM embody both: they support the measurable, disease-focused elements of PCC while integrating the holistic, relational components of person-centered care. This duality makes them one of the most practical ways to apply these principles at scale.

Core principles of patient-centered care

Patient-centered care is grounded in a set of core principles that guide how clinicians understand, communicate with, and support the people they care for. These same principles create the behavioral and relational groundwork that value-based care relies on to achieve meaningful outcomes.

1. Empathy and respect

PCC treats each patient as an individual whose values and experiences matter in guiding care. This is the basis of trust and meaningful engagement. Trust strengthens satisfaction and adherence, two factors that influence chronic disease outcomes, utilization patterns, and overall performance under VBC.

2. Holistic, biopsychosocial understanding

Patient-centered care requires looking beyond symptoms to understand the full context of a patient’s health—the biological, psychological, and social factors that influence how they manage illness day to day. This includes exploring the patient’s concerns, the circumstances shaping their decisions, and the supports or barriers affecting their ability to follow through on care plans.

Holistic understanding is essential in identifying barriers that drive avoidable utilization, supporting chronic disease control, and improving long-term outcomes.

3. Individualized care tailored to context

PCC requires care that is both respectful and individualized. Decisions are shaped through a therapeutic relationship in which the patient’s preferences, capabilities, family situation, and social context inform the care plan. Plans tailored to real-life circumstances are more sustainable and improve adherence, directly impacting chronic disease metrics and cost trends.

4. Shared power and decision-making

PCC shifts from directive care to partnership. Patients are viewed as experts in their own lives, and clinicians share power and responsibility through collaborative decision-making and goal-setting.

When patients choose treatment paths aligned with their values and capacity, they are more likely to follow them, which reduces waste and improves measurable outcomes.

5. Effective, two-way communication

Clear, responsive, and honest communication reduces information gaps between patients and clinicians. Research shows that effective communication improves decision-making and decreases unnecessary or inappropriate interventions that arise from misunderstanding or physician-induced demand.

Better communication leads to more appropriate utilization, stronger engagement, and fewer costly missteps.

6. Therapeutic relationship and continuity

A defining element of patient-centered care is relational continuity: a consistent, ongoing relationship between patient and clinician. Person-centered literature expands this view to emphasize long-term, collaborative partnerships rather than episodic encounters.

Continuity supports better chronic disease control, strengthens trust, and reduces fragmentation—three key drivers of value-based performance.

7. Coordinated and integrated care

Care coordination connects services across teams, settings, and time, ensuring patients experience care as an integrated pathway rather than a series of disconnected encounters. When information, responsibilities, and follow-up are clearly shared, patients receive timely support, clinicians make better-informed decisions, and gaps in care are less likely. This reduces duplication, prevents readmissions, and minimizes preventable ED visits.

8. Accessibility and flexibility of services

PCC requires that care be accessible, flexible, and easy to navigate, whether through extended hours, digital options, culturally responsive care, or environments that support engagement. When patients can reach their care team easily and receive support in ways that fit their daily lives, they are more likely to seek help early, manage chronic conditions consistently, and avoid crisis-driven utilization.

9. Empowerment, enablement, and activation

PCC expands the patient’s role in their own care by building confidence, knowledge, and capability. This can improve physical and mental well-being, support patient self-management, and reduce unnecessary interventions. Activated patients are more engaged, more adherent, and more cost-effective to care for.

The relationship between patient-centered care and value-based care

Where PCC and VBC align

Value-based care defines value as the health outcomes that matter to patients relative to the cost of achieving them. Patient-centered care reinforces this idea, centering care on the patient’s perspective rather than the clinician or payer perspective. It draws on dimensions such as shared power, therapeutic alliance, biopsychosocial understanding, coordinated care, and recognition of the clinician as a person—all aspects that support outcomes patients value.

At a conceptual level, PCC and VBC are remarkably aligned. Both aim to improve outcomes that matter to patients, promote more sustainable care, and support decisions that reflect patient priorities. PCC provides the behavioral and relational foundation that VBC models depend on to achieve meaningful results.

Where tensions arise

In practice, however, VBC and PCC do not always reinforce one another.

Many VBC initiatives rely on standardized outcome sets, such as those created by the International Consortium for Health Outcomes Measurement or those set by the Centers for Medicare and Medicaid Services, and pre-set definitions of success. These measures are valuable for benchmarking and performance assessment at a population level. But they do not always capture what matters to an individual patient, even when patients help design them.

Additionally, value-based healthcare studies often measure quality from the perspective of the provider, institution, or payer rather than through patient-centered metrics.

PCC and VBC can pull in different directions if patient-centered outcomes, preferences, and experiences are not explicitly embedded into quality measures, contracts, and daily workflows.

How care management programs help bridge PCC and VBC

This disconnect between philosophy and practice is exactly where care management programs play a pivotal role. Programs like CCM and APCM provide sustained, structured engagement between visits, which is where most patient challenges and decisions actually occur. They naturally reinforce PCC principles through:

Holistic assessment of needs and barriers
Shared decision-making and goal-setting
Condition-specific education and coaching
Care coordination across settings
Support for social, emotional, and practical challenges
Ongoing activation and self-management

For organizations operating under VBC, these same programs directly influence the metrics that matter most:

Reduced ED utilization
Lower readmission rates
Improved chronic disease management
Fewer gaps in care
Better documentation and reimbursement for complex patients
Earlier identification of Social Determinants of Health-related obstacles that drive cost

Care management programs create the operational infrastructure that allows patient-centered care to flourish consistently, not just during appointments.

This is also where a care management partner like ChartSpan can extend a practice’s capacity, embedding PCC behaviors at scale while driving the outcomes and cost efficiencies VBC rewards.

How patient-centered care strengthens value-based care performance

When PCC principles are applied consistently, they influence clinical results, patient experience, utilization patterns, and cost efficiency.

Improved outcomes in chronic disease and mental health

Patient-centered care contributes to better outcomes across several high-priority conditions, including:

Depression and anxiety
Cardiovascular risk management
Diabetes
Addictive behaviors

PCC strengthens by improving communication, clarifying goals, and helping patients participate more effectively in their own care.

Lower rates of avoidable and low-value care

By improving communication and reducing information gaps between patients and clinicians, PCC supports more appropriate clinical decision-making. It can lead to reductions in unnecessary interventions.

When patients understand their condition, participate in decisions, and receive clear explanations, superfluous testing and overtreatment decline. By aligning care with what patients actually need, rather than what might be assumed, PCC reduces avoidable procedures and the avoidable costs that follow.

Stronger engagement, adherence, and experience

Across diverse studies, PCC has been associated with:

Greater patient engagement
Improved adherence to treatment plans
Higher satisfaction and trust
Enhanced perceptions of care quality

Engaged patients communicate more openly, follow treatment plans more consistently, and are better equipped to manage chronic conditions. Patient experience, adherence, and engagement directly influence performance on quality metrics, STAR ratings, CAHPS scores, and chronic condition benchmarks.

Cost-effectiveness and system performance

PCC has demonstrated positive effects at both the patient and system level, including:

Improved physical and mental well-being
Decreased perceived necessity of hospitalization
Reduced unnecessary or inappropriate interventions

Over time, these benefits contribute to:

Lower cost per patient
Reduced preventable ED visits and readmissions
Better performance on cost and utilization benchmarks
Greater financial sustainability in value-based models

How to measure patient-centered care

Measurement is one of the biggest challenges in operationalizing PCC. Unlike traditional clinical metrics, patient-centeredness must be captured through what patients experience, perceive, and find meaningful, but many existing tools weren’t designed with that perspective in mind.

Common approaches to measuring PCC

The Health Foundation identifies three primary methods for assessing patient- and person-centered care: patient surveys or interviews, clinician surveys, and observation of clinical encounters. These methods help organizations understand how PCC is defined by patients and clinicians, what patients prefer, whether care felt patient-centered, and whether PCC improved health, well-being, or satisfaction.

To strengthen measurement, many organizations also use PROMs (Patient-Reported Outcome Measures) and PREMs (Patient-Reported Experience Measures). While valuable, these tools have notable constraints.

PROMs often prioritize system-centric clinical outcomes rather than what truly matters to patients, and PREMs may overlook relational or contextual elements of PCC. In some specialties, such as oncology, no PROM yet captures all dimensions of patient-centered care.

PROMs and PREMs contribute important insights but cannot, on their own, fully evaluate how patient-centered a care model truly is.

Designing a measurement framework that supports VBC

To link PCC meaningfully to value-based performance, organizations need a layered measurement strategy that accounts for both patient experience and clinical outcomes.

A practical framework includes:

Process measures

Capture whether PCC behaviors are being delivered.

Communication quality
Shared decision-making practices
Consistent SDOH screening and follow-through

Experience measures

Capture whether care felt patient-centered.

Trust in the care team
Feeling heard and respected
Ability to navigate the system easily

Outcome measures

Capture whether PCC leads to better health and lower utilization.

Chronic disease control (A1c, BP, lipids)
Readmissions and ED visits
Mental health and well-being measures

How care management programs strengthen measurement and ROI

Care-management programs like CCM and APCM generate structured data that makes PCC measurable at scale. This includes:

Regular outreach documentation
Barriers identified and resolved
SDOH needs tracked and addressed
Escalations, care plan updates, and education delivered

For financial leaders, these programs produce evidence of PCC’s ROI, such as:

Reductions in hospital claims and ED visits
Improved chronic disease control
Cost-of-care reductions per patient, per year
Stronger performance across VBC contracts

Care management programs help transform PCC from a relational ideal into an operationally trackable, financially quantifiable model of care.

How ChartSpan embeds patient- and person-centered care into value-based care performance

ChartSpan’s CCM and APCM programs embed both patient- and person-centered principles into everyday care by supporting the relationships, context, and continuity that drive better outcomes. The trust, individualized support, clear communication, and coordinated care established directly influence the quality, utilization, and cost measures at the heart of value-based care.

By sustaining engagement between visits and addressing the real-world factors that shape health, ChartSpan helps organizations deliver care that is genuinely centered on patients while improving performance in value-based models.

Relationship-based, personalized care

ChartSpan builds the relational foundation that patient-centered care depends on by:

Developing ongoing familiarity with each patient’s goals, preferences, family dynamics, and health context
Creating individualized care plans that reflect the patient’s capabilities and priorities—and sharing those plans with patients and authorized caregivers
Reinforcing shared decision-making by revisiting goals, addressing questions, and ensuring patients understand the “why” behind their care plan
Providing clear, accessible education to both patients and caregivers so they can make informed decisions and participate confidently in care

Coordinated, accessible, frequent support

ChartSpan strengthens continuity and reduces fragmentation by:

Coordinating care across providers, ensuring treatment plans stay aligned
Offering 24/7 clinical support so patients and caregivers can navigate urgent concerns without defaulting to the ED
Identifying and addressing SDOH barriers such as transportation, food access, housing challenges, and medication affordability
Supporting family and caregivers with education, updates, and guidance so they can reinforce care at home

Improved value-based care performance

By embedding patient-centered principles into daily care, ChartSpan enables organizations to:

Improve chronic disease control and preventive care completion
Reduce ED use, hospitalizations, and readmissions
Strengthen experience, trust, and engagement—key drivers of quality scores
Resolve barriers earlier, before they escalate into costly episodes
Provide documented evidence of cost-of-care reductions and ROI

A strategic partner for patient-centered, value-driven care

If you’re navigating the demands of value-based care, the challenge isn’t deciding whether patient-centered care matters, but building a system that delivers it consistently across your entire population. ChartSpan gives your organization the care management infrastructure, clinical staff, and ongoing support needed to make that possible.

If you’re ready to strengthen patient-centered care and improve value-based care performance, ChartSpan can help you build a sustainable, measurable model that scales with your goals.

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