Goal-Oriented Healthcare

Welcome

Welcome to our website. We are family physicians, 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 will both convince you and help you implement this practical person-centered approach. If you have additional questions or need help, please contact any of us by e-mail at the addresses provided at the bottom of each page.    

Overview

Goal-oriented healthcare is a practical approach to integrated, person-centered care. By focusing on life goals, it establishes a language and purpose that empower individuals to actively engage in decision-making, ensuring that interventions align with what matters to them. For clinicians and their patients, goal-oriented care supports meaningful relationships and respectful collaboration. For clinicians, it enhances the joy of practice while improving patient outcomes, and it assures that all members of the clinical team are on the same page.

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 problem-oriented care, complementary and alternative medicine, functional medicine, and personalized medicine, when appropriate.

It is based on a simple idea—agree on the goals before considering strategies—but its implications and impact on the entire healthcare system will be significant, including:

• The role and importance of primary healthcare (the place where goals are usually clarified);
• The nature and purpose of clinician-patient relationships and decision-making;
• A greater emphasis on prevention, long-term planning, and prioritization. Recognition of the importance of longitudinal studies, non-invasive autopsies, and better predictive algorithms (to improve prioritization of preventive strategies);
• Facilitation of interdisciplinary teamwork;
• The design of clinical record systems; and
• The definition and measurement of quality of care.

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 Am Geriatr Soc 2016; 2016: 15-18 https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.13866

Person-centered care: “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.”

https://www.cms.gov/priorities/innovation/key-concepts/person-centered-care

Health is the ability to derive maximum benefits from life’s journey…a journey filled with both challenges and opportunities for joy, fulfillment, and personal growth and development.

A goal is a desired outcome reflecting a person’s needs, desires, preferences, and values, about which it makes little or no sense to ask, “so that …?” (See examples below.) It can stand on its own and is not a step on the pathway to another outcome.

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 the 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 if and when they impact goal achievement.

Priorities are goals of greatest importance.

Examples of Personal Goals

Goal-oriented healthcare 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.

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.

I want to try that new medication (strategy) so maybe 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 those in 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 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).

Some 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 encourage 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.

1. 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
2. Reuben DB, Tinetti ME. Goal-oriented patient care–an alternative health outcomes paradigm. N Engl J Med. 2012 Mar 1;366(9):777-9.
3. 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 derive from identified problems (for example, blood pressure control, reducing the symptoms of heart failure). In goal-oriented care, treatments of problems 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, ability to engage in meaningful activities).

Clinicians often assume that goal-oriented care requires formal goal setting, a process they view as time consuming and difficult. Actually, the goals already exist. They only need to be clarified for each individual, and that turns out to be relatively easy in most cases.

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 is complex.

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 Institute for Healthcare Improvement and the American Geriatrics Society have endorsed an approach to age friendly care that focuses on the 4 M’s, Mobility, Mentation, Medications, and what Matters to the patient. It is another example of a mixed approach that includes a focus on quality of life as a goal. https://www.americangeriatrics.org/sites/default/files/inline-files/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf

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.