Overview
Goal-oriented healthcare offers a practical approach to delivering integrated person-centered healthcare. Goal clarification assures that all members of the clinical team are working toward the same outcomes. And by emphasizing universal life goals, it establishes a clear language and purpose that empower individuals to actively engage in decision-making, ensuring that healthcare interventions align with what truly matters to them.
Because it mainly influences the why and whether of clinical care, it integrates seamlessly with a wide range of approaches that focus on the what and how of care, including traditional problem-oriented care, complementary and alternative medicine, functional medicine, and personalized medicine, whenever appropriate.
It is based on a simple idea—agreeing on goals before considering strategies—but its implications and potential impact on the entire healthcare system will be significant, including:
The role and importance of primary healthcare (the place where goals are most often clarified);
The nature of clinician-patient relationships and decision-making (co-creative and collaborative);
A greater emphasis on prevention and long-term planning (e.g., problems are framed as risk factors and prioritization is enabled);
Facilitation of interdisciplinary teamwork (common goals);
Recognition of the importance of longitudinal studies, non-invasive autopsies, and better predictive algorithms (to improve prioritization of preventive strategies);
The design of clinical record systems (goal-oriented rather than problem-oriented); and
The definition and measurement of quality of care (individualized and process-oriented measures).
Definitions
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.”
AGS Expert Panel on Person-Centered Care. J Amer Geriatr Soc 2016; 2016: 15-18 https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.13866
Tanenbaum SJ. What is patient-centered care? A typology od models and missions. Health Care Anal, 2015; 23: 272-287. https://pubmed.ncbi.nlm.nih.gov/23807735/
A goal is a desired outcome about which it makes little sense to ask, “so that you can (do what)?” Goals are universal in type but unique, in their specifications, to each person.
An objective is a measurable step on the path toward a goal.
A strategy is an intervention, approach, or tactic employed in order to achieve a goal.
Values are underlying principles and beliefs that underlie and justify goals.
Risk factors are genetic, socioeconomic, behavioral, and acquired characteristics and conditions that make specific outcomes (e.g., premature death or disability) more likely.
Problems are viewed as obstacles, challenges, or opportunities when they impact goal achievement.
Priorities are goals of greatest importance.
Examples of Personalized Goals
Survival:
I want to stay alive until I can no longer enjoy thinking.
I want to stay alive until I can no longer recognize members of my own family.
I want to live long enough to see my youngest grandson graduate from college (goal).
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 die even if my thinking is impaired.
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 my living will on the refrigerator (strategy).
Positive Features of Goals
They belong to the person seeking assistance, not to the clinician or healthcare system.
They incorporate the full range of health concerns (prevention, life events like pregnancy and death, social determinants of health).
They create an optimistic process with no clear upper limits.
They support prioritization.
They inspire self-comparisons over time rather than comparison to others.
They help build/strengthen relationships.
They enable healthcare teamwork.
They can illuminate conflicts and reduces misunderstandings.
They can reduce unnecessary and unwanted tests and treatments so should improve safety so should reduce cost of care.
Rationale
The current medical approach performs well when patients have single, straightforward health issues that can be diagnosed and treated without causing significant harm. However, the aging of the population, an increasing emphasis on prevention, an increase in the prevalence of chronic diseases, and the expansion of diagnostic and treatment options have pushed it to its limit. Emphasizing diseases rather than the individuals experiencing them is now contributing to over-diagnosis, over-treatment, fragmented care, de-personalization, and rising costs. A new paradigm is essential—one that humanizes care while thoughtfully applying medical science to address the unique priorities of each person.
- Mold JW. Failure of the problem-oriented medical paradigm and a person-centered alternative. Ann Fam Med 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. N Engl J Med. 2012 Mar 1;366(9):777-9.
- Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med. 1991 Jan;23(1):46-51.
Errors and Misconceptions
A common misconception about goal-oriented care is that the goals we are proposing derive from identified problems (for example, control of blood pressure). In goal-oriented care, those are considered to be strategies, not goals. Risk factors like elevated blood pressure are addressed when they relate to the patient’s broader goals (e.g., life prolongation).
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).
Many clinicians worry that shifting the focus from problems to goals could worsen disease-oriented quality metrics. This may or may not be true. However, one could argue that linking disease control strategies to individual goals might boost adherence, offsetting any declines from less emphasis on disease-specific measures.
A common misconception is that goal-oriented care takes more time than traditional problem-focused care. In reality, it just involves a different type of conversation.
Others worry that goal-oriented care is less clinically rigorous than traditional care. The opposite is true. Shifting the focus to goals requires a greater level of knowledge of clinical medicine including the natural histories of diseases and the size of the comparative benefits of preventive and treatment strategies.
Some physicians have raised concerns that a goal-oriented approach might cause them to overlook important issues. Although it is certainly wise to exercise caution when adopting any new method, 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 that humanizes care for individuals of all ages, recognizing that everyone has unique complexities.
Some believe that goal-oriented care simply means discovering what each person wants and helping them achieve it. In reality, goal clarification is a collaborative, co-creative process that requires the full engagement of everyone involved.
Finally, many physicians believe they are already delivering goal-oriented care. Experienced doctors who have served the same community for years and genuinely care about their patients often think in terms of goals. However, few have fully adopted all aspects of goal-oriented care.
Variations and Alternatives
Patient Priorities Care is a model of goal-oriented care developed by Mary 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 as the goal. Online implementation and training materials are available.
The Veterans’ Administration has implemented a process of care called Whole Health Clinical Care.
Health Tapestry is an approach being tested in Ontario, Canada using older 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 only two fully developed approaches for delivering person-centered care.
The other, narrative medicine, which focuses on each person’s life story, is complimentary to and fully 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.