Goal-Oriented Healthcare

A Person-Centered Paradigm

Evidence

The comprehensive goal-oriented approach described and advocated here has not yet undergone full evaluation. However, several elements of the model have been examined, yielding positive outcomes, including the following.

Prevention of Premature Death

When individuals and their physicians are given information about life expectancy and the projected impact of various preventive strategies, they are more likely to implement preventive measures and to choose higher impact strategies resulting in substantial gains in life expectancy.   

  1. Nagykaldi ZJ, Jordan M, Quitoriano J, Ciro CA, Mold JW. User-Centered Design and Usability Testing of an Innovative Health-Related Quality of Life Module. Applied Clinical Informatics, 2014; 5(4):958-970. https://www.thieme-connect.com/products/ejournals/pdf/10.4338/ACI-2014-08-RA-0067.pdf
  2. Taksler GB, Mercer MB, Fagerlin A, and Rothberg MB. Assessing patient interest in individualized preventive care recommendations. MDM Policy and Practice, 2019; 4(1): 1-14. https://journals.sagepub.com/doi/full/10.1177/2381468319850803
  3. Taksler GB, Hu B, DeGrandis Jr F, Montori VM, Fagerlin A, Nagykaldi Z, and Rothberg MB. Effect of individualized preventive care recommendations vs usual care on patient interest and use of recommendations: A pilot randomized clinical trial. JAMA Network Open, 2021; 4(11): e2131455 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785668
  4. Applegate, M., Scott, E., Taksler, G.B. et al. Project ACTIVE: a Randomized Controlled Trial of Personalized and Patient-Centered Preventive Care in an Urban Safety-Net Setting. J Gen Intern Med, 2021; 36, 606–613.  https://link.springer.com/article/10.1007/s11606-020-06359-z

Quality of Life

If asked appropriately worded questions about quality-of-life goals, patients have very little trouble answering them. However, physicians without additional training in goal-oriented care often have difficulty incorporating patients’ quality of life goals into their recommendations.

  1. Purkaple BA, Nagykaldi ZJ, Allahyar A, Todd R, Mold JW. Physicians’ Response to Patients’   Quality-of-Life Goals. J Am Board Fam Med 2020; 33: 71–79. https://www.jabfm.org/content/jabfp/33/1/71.full.pdf
  2. Purkaple BA, Mold JW, and Chen S. Encouraging patient-centered care by including quality-of-life questions on pre-encounter forms. Ann Fam Med 2016; 14(3): 221-226. https://www.jabfm.org/content/33/1/71
  3. Tinetti ME, Costello DM, Naik AD, Davenport C, Hernandez-Bigos K, Van Liew JR, Esterson J, and Dindo L. Outcome goals and health care preferences of older adults with multiple chronic conditions. JAMA Network Open, 2021; 4(3): e211271. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2814211

When physicians trained in goal-oriented care are provided with information about their patients’ goals and values, they order fewer diagnostic tests, fewer new medications, and recommend fewer self-management tasks, which results in reduced patient burden. They also make more referrals to physical therapists and to community services and supports.

  1. Tinetti M, Naik AD, Dindo L, Costello DM, Esterson J, Geda M, Rosen J, Hernandez-Bigos K, Smith CD, Ouellet GM, Kang G, Lee Y, and Blaum C. Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Intern Med, 2019; 179(12): 1688-1697. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2752365
  2. Freytag J, Dindo L, Catic A, Johnson AL, Amspoker AB, Gravier A, Dawson DB, Tinetti ME, and Naik AD. Feasibility of Clinicians Aligning Health Care with Patient Priorities in Geriatrics Ambulatory Care. J Amer Geriatr Soc, 2020; 68: 2112-2116. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.16662

In a dementia care management program at an academic medical center, a goal-oriented process involving patients, caregivers, and nurse practitioners had the following results. Eighty-four percent of participant goals were non-medical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met.

  1. Jennings LA, Ramirez KD, Hays RD, Wenger NS, Reuben DB. Personalized goal attainment in dementia care: Measuring what persons with dementia and their caregivers want. J Amer Geriatr Soc 2018; 66(11): 2120-2127. Personalized Goal Attainment in Dementia Care: Measuring What Persons with Dementia and Their Caregivers Want – Jennings – 2018 – Journal of the American Geriatrics Society – Wiley Online Library

In a primary care study, when patients’ goals and values were elicited by trained community volunteers and communicated to their primary care physicians , hospitalizations were reduced (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). In a congestive heart failure clinic, implementation of a person-centered, goal-oriented approach was associated with a 58% reduction in unplanned hospitalizations and a significant reduction in average length of hospitalizations. Patients also reported improvements in self-rated health and quality of life.

  1. Dolovich L, Oliver D, Lamarche L, Thabane L, Valaitis R, Agarwal G, Carr T, Foster G, Griffith L, Javadi D, Kastner M, Mangin D, Papaioannou A, Ploeg J, Raina P, Richardson J, Risdon C, Santaguida P, Straus S, Price D. Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial. CMAJ. 2019 May 6;191(18):E491-E500. Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial – PubMed
  2.  Mun JKS, Xuan SY, Sim GWC, Shan ROH, Earn LC. A person-centered, relationship-based model of care for heart failure patients in Singapore. https://catalyst.nejm.org/doi/full/10.1056/CAT.24.0053

In a randomized trial, goal-directed occupational therapy improved the functional status, life satisfaction, vitality, social functioning, and general mental health of independent-living older adults.

  1. Clark F, Azen SP, Zemke R, Jackson J, Carlson M. Mandel D, Hay J, Josephson K, Cherry B, Hessel C, Palmer J, and Lipson L. Occupational Therapy for Independent-Living Older Adults: A Randomized Controlled Trial. J Amer Med Assoc, 1997;278:1321-1326. https://jamanetwork.com/journals/jama/article-abstract/418441

A 10-session home-based interprofessional functional goal-directed intervention (CAPABLE) consistently improves ADLs and ADLs and reduces costs of care in low income, community dwelling, cognitively intact older adults with difficulty with one or more ADL.

  1. Szanton SL, Leff B, Li Q, Breysse J, Spoelstra S, Kell J, Purvis J, Xue Q-L, Wilson J, and Gitlin LN. CAPABLE program improves disability in multiple randomized triels. J Am Geriatr Soc, 2021;69:3631-3640. www.agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17383

Good Death

Goal concordant palliative care improves quality of life, reduces burden, and reduces emergency room visits and health care costs.

  1. Milazzo S, Hansen E, Carozza D, Case AA. How Effective Is Palliative Care in Improving Patient Outcomes? Curr Treat Options Oncol. 2020 Feb 5;21(2):12. https://pubmed.ncbi.nlm.nih.gov/32025964/
  2. Jeung YS, Bae SA, Lee SY, Sim J-A, Keam B, Yoo SH. ED visits among patients with advanced cancer referred to outpatient palliative care. JAMA Network Open. 2025;8(7):e2521101. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2836410