Welcome
Welcome to our website. We are family physicians, current and former professors of Family Medicine and Internal Medicine, and researchers from the United States, Canada, and Belgium who believe that goal-oriented care is a better way to provide healthcare, better for patients, better for clinicians, and a better way to organize a healthcare system. We hope the information and resources we have provided here will both convince you of that and help you implement this practical person-centered approach to care. If you have questions or need help, please reach out to any of us by e-mail at the addresses provided at the bottom of each page.
Goal-oriented care is a practical way to provide person-centered healthcare. In contrast to the traditional deficit reduction model that focuses on solving problems, goal-oriented care promotes optimization of health by focusing on relevant life goals. It empowers individuals to engage in decision-making and ensures that interventions align with what matters most to them. For clinicians, it enhances the joy of practice and facilitates interdisciplinary teamwork.
Because it primarily shapes the why and whether of clinical care, it can integrate seamlessly with a wide range of approaches to the what and how of care, including traditional medical care, complementary and alternative medicine, functional medicine, and personalized medicine. It is also compatible with and enhanced by the principles and techniques of relationship-centered care .
While it is based on a simple principle—agree on the goals before considering interventions—its implications and impact on the entire healthcare system will be significant, including:
- Elevating the role and status of primary care, the place where goals are typically clarified;
- Clarifying the nature and purpose of clinician-patient relationships and decision-making;
- Emphasizing prevention, long-term planning, and prioritization and recognition of the importance of longitudinal studies, non-invasive autopsies, and better predictive algorithms (to improve prioritization of preventive strategies);
- Facilitating interdisciplinary teamwork;
- Improving clinical record systems; and
- Redefining quality of care in terms of its likelihood to contribute to goal achievement.
The current disease-oriented approach to care works well when people have single health problems that can be diagnosed and treated without causing significant harm. However, the aging of the population, an increase in the prevalence of chronic diseases, the expansion of diagnostic and treatment options, and our ability to anticipate and prevent health problems have pushed disease-oriented care to its limit. Focusing on diseases rather than on the individuals experiencing them is contributing to fragmentation of care, over-diagnosis, over-treatment, and rising costs. A new conceptualization is needed—one that humanizes care while thoughtfully guiding the application of medical science to address the unique priorities of each person.
- Mold JW. Failure of the problem-oriented medical paradigm and a person-centered alternative. Annals of Family Medicine 2022; 20:145-148. https://www.annfammed.org/content/annalsfm/20/2/145.full.pdf
- Reuben DB, Tinetti ME. Goal-oriented patient care–an alternative health outcomes paradigm. New England Journal of Medicine 2012 Mar 1;366(9):777-9.
- Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Family Medicine 1991 Jan;23(1):46-51.
Person-Centered Care
“Person-centered care means that individuals’ values and preferences are elicited and once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires.”
American Geriatrics Society Expert Panel on Person-Centered Care. J Am Geriatr Soc 2016; 2016: 15-18. https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.13866
“Integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values and preferences, in a system that supports good provider–patient communication and empowers individuals receiving care and providers to make effective care plans together.”
Centers for Medicare and Medicaid Services. https://www.cms.gov/priorities/innovation/key-concepts/person-centered-care
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Goal-Oriented Care
A Person-Centered Approach
Health is the ability to derive maximum benefit from life’s journey…a journey filled with both challenges and opportunities for pleasure, joy, fulfillment, and personal growth.
Goals are outcomes that reflect a person’s values, needs, desires, and preferences, and about which it makes no sense to ask, “so that …? or in order to …?” A goal can stand on its own. It is not a step on the path to another outcome.
Objectives are measurable steps on the path toward a goal.
Strategies are interventions, approaches, or tactics employed in order to achieve a goal.
Values are the underlying principles and beliefs that underlie and justify goals.
Risk factors are genetic, socioeconomic, behavioral, and acquired characteristics, conditions, and circumstances that make future outcomes (e.g., premature death or disability) more likely.
Problems are viewed as obstacles, challenges, or opportunities if and when they impact goal achievement. If unrelated to personal goals, they are documented and ignored.
Priorities are goals of greatest importance to the individual.
Trade-offs are conscious decisions to pursue particular goals even though it means giving up or lowering the commitment to other goals.
Goal-oriented care assumes that there are four types of goals: 1) survival; 2) maximization of quality of life; 3) optimization of personal growth and development; and 4) a good death.
While these goals are derived from the definition of health, they are in fact life goals. Within goal-oriented care, there is no distinction between life and health goals. The focus is on optimizing the life of the individual.
Survival:
I want to live as long as possible.
I want to stay alive until I can no longer enjoy thinking.
I want to try that new medication (strategy) so that I can stop smoking (objective) so that I can live long enough to finish the book I am writing (goal). I want to make a contribution to my profession (value).
Quality of Life:
I want to be able to take care of my dog.
I want to avoid knee replacement surgery.
I want to lose 30 pounds (objective) so that I will not be an embarrassment to my grandchildren (goal). I think I can make a positive contribution in their lives (value). I want try to try one of those new weight loss drugs (strategy).
Growth and Development:
I want learn to be more empathic.
I want to repair my relationship with my father.
I need your help (strategy) to convince my husband (objective) that it’s time for our daughter to move out of our house for good (goal).
Good Death:
I don’t want to be in pain when I am dying even if it means that my thinking is impaired.
If at all possible, I want to die in my sleep, even if it means I don’t live as long.
I want to stay in my own home (goal) until I die, unless and until that creates a burden for my children (value). I have put a copy of my living will on the refrigerator (strategy).
They are motivational, supporting all three basic psychological needs: relatedness, autonomy, and competence (https://www.selfdeterminationtheory.org/)
They belong to the person seeking assistance, not to the clinician or healthcare system.
They incorporate the full range of health concerns (prevention, normal life events like pregnancy and death, social determinants of health, etc.).
They create an optimistic process with no upper limits. “Normal” is largely irrelevant.
They encourage and facilitate prioritization, which can reduce unhelpful testing and interventions.
They inspire self-comparisons rather than comparison to others.
They contribute to greater understanding and relationship-building.
They enable effective healthcare teamwork.
They can illuminate conflicts and reduces misunderstandings.
They can reduce unnecessary and unwanted tests and treatments, improving safety and reducing cost.
A common misconception about goal-oriented care is that goals are derived from problems. In goal-oriented care, resolving a problem, when relevant to goal achievement, is an objective, not a goal. Actions taken to solve the problem are strategies.
Clinicians often assume that goal-oriented care involves goal setting, a process they view as time consuming and difficult. Actually, the goals already exist. They just need to be confirmed and clarified for each individual, and that turns out to be relatively simple in most cases, though it requires a different set of questions from those used in disease-oriented care.
Some have argued that goal-oriented care is simply a semantic shift, exchanging the word goal for problem. Actually, goals and problems have very little in common (see Definitions above).
Many clinicians worry that shifting the focus from problems to goals could worsen disease-oriented quality metrics. That may or may not be true. Linking relevant disease management strategies to personal goals could boost adherence, offsetting any declines that might occur from individualization.
A common misconception is that goal-oriented care takes more time than traditional problem-focused care. While some visits (e.g., preventive care visits) may require more time, the overall time spent with each patient per year is likely to be about the same once the approach has been mastered and system supports are in place..
Others worry that goal-oriented care is less clinically rigorous than traditional care. Actually, the opposite is true. Shifting the focus from problems to goals requires a greater level of knowledge of clinical medicine including the natural histories of diseases, the comparative benefits of preventive and treatment strategies, and the application of population statistics to individuals.
Some physicians have raised concerns that a goal-oriented approach might cause them to overlook important medical problems. Although it is wise to exercise caution when adopting any new approach, there is no evidence that focusing on achieving goals causes problems to be missed.
Some believe that goal-oriented care applies only to older or more complex patients. In reality, it is a mindset and approach that humanizes care for individuals of all ages.
Some believe that goal-oriented care means discovering what each person wants and helping them to get it. In reality, goal clarification is a collaborative, co-creative process that requires the full engagement of everyone the patient chooses to involve.
Finally, many physicians believe they are already providing goal-oriented care. Experienced doctors who have served the same community of patients for years have often developed a goal-oriented mindset, but few have implemented all aspects of goal-oriented care.
Patient Priorities Care is a model of goal-oriented care developed by Mary Tinetti and her colleagues at Yale. It is designed for a subset of older people with multiple or complex health challenges and focuses primarily on quality of life. Online implementation and training materials are available.
The Institute for Healthcare Improvement and the American Geriatrics Society have endorsed an approach derived from Patient Priorities Care called Age Friendly Care that focuses on the 4 M’s, Mobility, Mentation, Medications, and what Matters to the patient.
The Veterans’ Administration has implemented a process of care called Whole Health Clinical Care. The Patient Priorities Care Model is also being tested in some VA clinics.
Health Tapestry is an approach being tested in Ontario, Canada using community volunteers to help patients clarify their values and goals prior to seeing their primary care clinicians.
In Flanders, Belgium, primary care clinicians are being trained in a version of goal-oriented care that emphasizes quality of life goals and includes clinical team goal-setting as well.
Goal-oriented care is one of two fully developed clinical approaches to person-centered care. The other, Narrative Medicine, which focuses on each person’s life story, is complimentary to and compatible with goal-oriented care. It is a comprehensive diagnostic and therapeutic approach that utilizes patients’ narratives in clinical practice, research, and education to promote healing. Beyond attempts to reach accurate diagnoses, it aims to address the relational and psychological dimensions that occur in tandem with physical illness. Narrative medicine aims not only to validate the experience of the patient, but it also encourages creativity and self-reflection in the physician.