My Wellbeing Journal: Development of a communication and goal‐setting tool to improve care for older adults with chronic conditions and multimorbidity

Abstract

Abstract Background Chronic conditions and multimorbidity, the presence of two or more chronic conditions, are increasingly common in older adults. Effective management of chronic conditions and multimorbidity in older adults requires a collaborative and person‐centred approach that considers the individual's goals, preferences and priorities. However, ensuring high‐quality personalised care for older adults with multimorbidity can be challenging due to the complexity of their care needs, limited time and a lack of patient preparation to discuss their personal goals and preferences with their healthcare team. Objective To codesign a communication and goal‐setting tool, My Wellbeing Journal, to support personalised care planning for older adults with chronic conditions and multimorbidity. Design We drew on an experience‐based codesign approach to develop My Wellbeing Journal. This article reports on the final end‐user feedback, which was collected via an online survey with older adults and their carers. Setting and Participants Older adults with chronic conditions, multimorbidity and informal carers living in Australia. Personalised care planning was considered in the context of primary care. Results A total of 88 participants completed the online survey. The survey focused on participants' feedback on the tool in terms of effectiveness, efficiency, satisfaction and errors encountered. This feedback resulted in modifications to My Wellbeing Journal, which can be used during clinical encounters to facilitate communication, goal setting and progress tracking. Discussion and Conclusions Clinicians and carers can use the tool to guide discussions with older adults about their care planning and help them set realistic goals that are meaningful to them. The findings of this study could be used to inform the development of recommendations for healthcare providers to implement person‐centred, goal‐oriented care for older adults with chronic conditions and multimorbidity. Patient or Public Contribution Older adults living with chronic conditions and multimorbidity and their carers have contributed to the development of a tool that has the potential to significantly enhance the experience of personalised care planning. Their direct involvement as collaborators has ensured that the tool is optimised to meet the standards of effectiveness and usability.

Keywords

• aged
• goal setting
• multimorbidity
• person‐centred care
• shared decision‐making