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Goal-oriented health care

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Goal-oriented health care, also known as goal-directed health care, goal-oriented medical care, and patient priorities care, is a form of health care delivery that is based on achieving individualized goals that are created through collaborative conversations between patients and providers in health care settings.[1] It is a form of Patient Centered Care/Person-Centered Care as the goals are unique to the individual patient and direct the plan of care. This is in contrast to problem-oriented or disease-driven care where the focus is on correcting biological abnormalities (i.e. for a patient with diabetes focusing on control of the hemoglobin A1c).[2] This philosophy of practice is become attractive in the medical community especially in primary care practices worldwide.

Background, history, and definition

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This philosophy was first coined in 1991 by James W. Mold, a family physician and geriatrician working at the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma, in an article published in the journal, Family Medicine.[3] He proposed that, before considering diagnostic and therapeutic strategies, clinicians and their patients should agree upon their goals.[4] He defined a goal as a desired outcome that is essential to the patient and proposed that four major goal types are relevant to health care: 1) prevention of premature (i.e., preventable) death and disability; 2) maximization of current health-related quality of life; 3) optimization of personal growth and development; and 4) improving the chances of a good death. Goal-directed health care is compatible with a wide variety of clinical strategies, including evidence-based medicine,[5] caring for patients with multimorbidity,[6][7][8] patient-centered care,[9][10] and shared decision making.[11][12]

Goal types

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The clinical methods used to help patients clarify and achieve their health-related goals are different for each goal type though the categories are inter-related.[13] The uniting factor of this conceptual framework is that the goal is formed in a discussion involving both the patient and the health care providers prior to the development of a plan of care that is based upon the patient's goals and priorities, resources and abilities, values and preferences.

Prevention of premature death and disability

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Preventing premature death is a basic tenet of medical and health theory.[14] All human beings want to stay alive as long as possible up to the point when life becomes unbearable, when death becomes a preferable alternative. For each person that point is different and must be determined and reviewed periodically.[15] Preventing premature death and disability can best be accomplished by preferentially implementing preventive strategies with the highest potential impact. A goal-directed approach therefore emphasizes the prioritization of preventive strategies. That process of prioritization includes consideration of all measures that a person might be willing to take to extend their life or prevent disability including primary, secondary, and tertiary preventive strategies.

Maximization of current quality of life

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Health-related quality of life is the ability to participate in both necessary and meaningful activities, defined broadly to include physical, cognitive, and interpersonal activities. The specific components of quality of life for each person are unique, and so measures taken to preserve and enhance quality of life will also differ.[16][17] This tenet is fundamental to the fields of Occupational Therapy and Sports Medicine and is routinely applied in palliative care, which utilizes a goal directed approach for patients with serious, chronic illnesses that balances prevention of death with optimizing quality of life.

Optimization of personal growth and development

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Growth and development are most often emphasized during childhood.[18] Within the goal-directed health care framework, growth and development are lifelong goals including not only childhood developmental tasks or milestones, but also resilience and coherence throughout life.[19][20][21] This requires the provider and patient to discuss personal growth and development goals and consider them when determining a treatment plan.

Improving the chances of a good death

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Making a good death a goal increases the importance of advance directives for all adults.[22] Beyond legal forms, it is also important to help patients document their values and preferences and discuss them with family members and caregivers utilizing prioritization to make sure relevant information is available at the point where critical decisions must be made.[23][24][25]

Research in the field

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A number of articles have been written describing the implementation and potential benefits of various aspects of goal-oriented care[26] and how to integrate it into our health system.[27][28][29] Several books have been written to help guide patients and practitioners.[30][31]

References

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  1. ^ Mold JW. Goal-directed health Care: Redefining Health and Health Care in the Era of Value-Based Care. Cureus. 2017;9(2):e1043. Published 2017 Feb 21. doi:10.7759/cureus.1043
  2. ^ Tinetti ME, Fried T. The end of the disease era. American Journal of Medicine. 2004;116(3):179-85
  3. ^ Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Family Med 1991;23(1):46-51.
  4. ^ Charette SL, Garcia MB, Reuben DB. Goal-oriented care. 2015:1-19
  5. ^ Mold, JW, Hamm R, Scheid,D. "Evidence-based medicine meets goal-directed care." Family Medicine, May 2003; 35 (5):360-4.
  6. ^ Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Medicine. 2014;12:223.
  7. ^ Harris MF, Dennis S, Pillay M. Multimorbidity: negotiating priorities and making progress.[Erratum appears in Aust Fam Physician. 2014 Jan-Feb;43(1):9]. Australian Family Physician. 2013;42(12):850-4
  8. ^ Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010;363(27):2611-20.
  9. ^ Blom JW, El Azzi M, Wopereis DM, Glynn L, Muth C, van Driel ML. Reporting of patient-centred outcomes in heart failure trials: are patient preferences being ignored? Heart Failure Reviews. 2015;20(4):385-92
  10. ^ Beverly EA. Incorporating comorbidity, values and preferences into clinical care guidelines designed for older adults living with type 2 diabetes. Dissertation Abstracts International Section A: Humanities and Social Sciences. 2011;71(12-A):4521
  11. ^ Mold, JW. Facilitating shared decision making with patients." American Family Physician. Oct 2006; 74 970: 1209-10,1212.
  12. ^ Fried TR, Tinetti ME, Iannone L. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Archives of Internal Medicine. 2011;171(1):75-80.
  13. ^ Reuben DB, Tinetti ME. Goal-oriented patient care - an alternative health outcomes paradigm. New England Journal of Medicine. 2012;366(9):777–9.
  14. ^ Chene, G. "Prevention of the causes of premature illness and death: making it happen." Lancet Public Health. Feb 2017; 2(2):e69-e70. doi: 10.1016/S2468-2667(17)30005-1. Epub 2017 Jan 14.
  15. ^ Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease- specific guidelines for patients with multiple conditions. N Engl J Med.
  16. ^ Purkaple, BA, Mold, JW, and Chen, S. Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms. Annals of Family Medicine, 2016;14(3), 221–226. https://doi.org/10.1370/afm.1905 LK
  17. ^ Lewis VJ, Dell L, Matthews LR. Evaluating the feasibility of Goal Attainment Scaling as a rehabilitation outcome measure for veterans. Journal of Rehabilitation Medicine. 2013;45(4):403-9.
  18. ^ Piaget J. The Psychology of the Child. Basic Books; 18 October 1969
  19. ^ Siebes RC, Ketelaar M, Gorter JW, Wijnroks L, De Blecourt AC, Reinders-Messelink HA, et al. Transparency and tuning of rehabilitation care for children with cerebral palsy: a multiple case study in five children with complex needs. Developmental neurorehabilitation. 2007;10(3):193-204
  20. ^ Boeckxstaens, P et al. "A High Sense of Coherence as Protection Against Adverse Health Outcomes in Patients Aged 80 Years and Older." Annals of Family Medicine. July 2016; 14(4) 337-343. doi: 10.1370/afm.1950
  21. ^ Rockwood K, Howlett S, Stadnyk K, Carver D, Powell C, Stolee P. Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment. Journal of Clinical Epidemiology. 2003;56(8):736-43.
  22. ^ Wickersham, E et al. "Improving the Adoption of Advanced Directives in Primary Care Practices." Journal of the American Board of Family Medicine. 2019 Mar-Apr;32(2):168-179. doi: 10.3122/jabfm.2019.02.180236.
  23. ^ Lum HD, Sudore RL. Advance Care Planning and Goals of Care Communication in Older Adults with Cardiovascular Disease and Multi-Morbidity. Clinics in Geriatric Medicine. 2016.
  24. ^ Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282.
  25. ^ Rabow MW, Hauser JM, Adams J. Supporting family caregivers at the end of life: "they don't know what they don't know". JAMA. 2004;291(4):483-91.
  26. ^ Rueben, D., Jennings, L. Putting Goal-Oriented Patient Care Into Practice. Journal of the American Geriatrics Society. 2019: ul;67(7):1342-1344. doi: 10.1111/jgs.15885. Epub 2019 Mar 18.
  27. ^ Nagykaldi Z, Yeaman B, Jones M, Mold JW, Scheid DC. HIE-I - Health information exchange with intelligence. J Ambul Care Manag 2013; 37(1): 20-31.
  28. ^ Vermunt NPCA, Harmsen M, Westert GP, Rikkert MGMO, Faber MJ. Collaborative goal setting with elderly patients with chronic disease or multimorbidity : a systematic review. 2017:1-12. doi:10.1186/s12877-017-0534-0
  29. ^ Nagykaldi, ZJ, Dave, AK, Watts, CJ, Utpala, TJ, Wickersham, E. Improving Patient-Clinician Conversations During Annual Wellness Visits. The Journal of the American Board of Family Medicine. 2017;30(2), 161–169. https://doi.org/10.3122/jabfm.2017.02.160229
  30. ^ Mold, James. Achieving Your Personal Health Goals: A Patient's Guide. Full Court Press: 25 October 2017.
  31. ^ De Maeseneer, Jan. Family Medicine and Primary Care: At the Crossroads of Societal ChangeLannoo Publishers: 9 November 2017.
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