A TRANSITION FROM DISEASE-CENTRED TO GOAL-DIRECTED INDIVIDUALISED CARE OF PATIENTS WITH MULTIPLE MORBIDITIES: A JOURNEY TO GOAL-ORIENTATED PATIENT HEALTHCARE

Abstract

Goal-orientated healthcare is multi-level strategic planning of medical care in which the patient’s goals are set first and, thereafter, their operationalisation is implemented into clinical practice. This is a novel approach to the management of patients with multiple morbidities. In this care model, the patients are treated as partners participating in a therapy process that is focussed on improving quality of life and health outcomes. This approach also facilitates the achievement of individually desired therapeutic targets by patients, their families, and/or their caregivers. The aim of this review is to present the concept of goal-orientated care based on current research from the medical literature and to describe some serious concerns related to the disease-centred model commonly used for patients with complex medical and/or mental conditions, such as the elderly. To illustrate the advantages and limitations of the goal-orientated patient care model, two exemplary cases of patients often seen in practice, such as primary care, cardiology, or geriatrics, are briefly described. The principles of goal-orientated patient care and available solutions to common problems should be useful to both the medical practitioners and their patients, in many contexts of multidisciplinary collaboration.

Keywords

• care team
• goal-orientated
• multidisciplinary
• multiple chronic conditions
• patient activation
• patient-centred care
• patient engagement