Goal-Oriented care: A catalyst for person-centred system integration

Context: Person-centred integrated primary care delivery is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation.

Objective: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels.

Study design: Theoretical concept mapping using comparative case studies to illustrate theoretical connections.

Setting: 3 interprofessional primary care practices delivering goal-oriented care in Ottawa (Canada), Flanders (Belgium), and Vermont (United States).

Population studied: Interprofessional primary care practices.

Intervention: Interprofessional teams delivering goal-oriented care.

Outcome measures: Describe how goal-oriented care advances clinical, professional, organizational and system level integration.

Results: The three cases demonstrate how goal-oriented care has the potential to catalyze integrated care. In Ontario, goal-oriented care enabled integration at clinical and professional levels, helping clinicians to work together across professional boundaries. In Vermont, the model enabled professional and organizational integration, helping professionals to work across organizational boundaries to support high needs patients. In Flanders, goal-oriented care is being adopted as part of a larger primary care system transformation. In all cases goal-oriented care served to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care.

Conclusions: The framework presented in this work helped to demonstrate how goal-oriented care can be used to establish a common vision and philosophy to drive shared processes, acting as a powerful tool to enable integrated care delivery. This comparative case work provides lessons for other systems seeking to provide integrated care within and across primary care teams.