Behavioural Change in Practice: Primary Care Providers’ Journey Towards Goal-Oriented Care

<h3>Context:</h3> 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. <h3>Objective:</h3> 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. <h3>Study design:</h3> Theoretical concept mapping using comparative case studies to illustrate theoretical connections. <h3>Setting:</h3> 3 interprofessional primary care practices delivering goal-oriented care in Ottawa (Canada), Flanders (Belgium), and Vermont (United States). <h3>Population studied:</h3> Interprofessional primary care practices. <h3>Intervention:</h3> Interprofessional teams delivering goal-oriented care. <h3>Outcome measures:</h3> Describe how goal-oriented care advances clinical, professional, organizational and system level integration. <h3>Results:</h3> 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. <h3>Conclusions:</h3> 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.

As healthcare systems transition toward person-centred integrated care (PC-IC), goal-oriented care (GOC) has gained prominence as a conceptual approach to aligning care with what matters most to patients. However, there is limited empirical insight of how GOC is enacted in daily practice and what competencies this requires from providers. This study explores how primary care providers enact GOC in daily practice to inform future training and competency development. A focused, team-based ethnographic approach was used, combining non-participant observations with short reflective interviews. Primary care providers were purposively sampled from a cohort who completed interprofessional GOC training, ensuring disciplinary diversity. Data were analysed using thematic analysis to identify behaviours and competencies underpinning GOC in practice. Providing GOC requires competencies beyond knowledge or task-specific skills, and is enacted through contextual, relational, and reflective competencies. Providers showed contextual awareness by linking care actions to patients' lived experiences and personal goals. They built relational trust through open, authentic, and non-hierarchical communication to co-create care decisions with patients. Reflective competence was shown when providers reassessed care decisions in light of patient goals, assumptions, and team input. These findings highlight the importance of strengthening reflective competencies in training of primary care providers. In practice, this entails supporting providers to reflect on their professional responsibilities, alongside those of the other disciplines they work with in health and social care; and critically engage with assumptions. This reflective capacity is key to embedding GOC in daily practice and aligning care with what truly matters to patients.

BackgroundThe policy shift towards person-centred integrated primary care systems drives interest in primary care across higher education programs. In Flanders, the Primary Care Academy (PCA) is established to support this policy shift. The PCA focusses on the concepts of goal-oriented care, self-management, and interprofessional collaboration to support the shift towards integrated care and to integrate them in curricula in order to strengthen and develop a futureproof health system. Therefore, the aim of this study is if and how lecturers implement these concepts in the curriculum and what they need for a successful implementation.MethodsA sequential explanatory mixed method study design was used combining quantitative and qualitative data. A cross-sectional survey was sent to 276 Flemish health care education programs. Qualitative data was collected through focus groups in which lecturers participated.ResultsThe results showed that 89% of the higher education programs address goal-oriented care, self-management, and interprofessional collaboration with regard to primary care. Further analysis of courses within the programs reveals that the concept of self-management is covered in only 58%, while goal-oriented care (73%) and interprofessional collaboration (80%) appear more frequently. The level at which the themes are addressed in the courses are often limited to an introduction.The focus groups revealed that primary care is present in education programs, however lecturers are limited aware where primary care is integrated in their own and other programs. Lectures expressed a need for more collaboration between research, education and practice in developing educational content. When new concepts are introduced, lecturers want them to be translated into educational content, learning objectives and competencies.ConclusionsThe study shows that the concepts of goal-oriented care, self-management, and interprofessional collaboration are present in higher education programs to a varying degree. Lecturers are eager to implement these new primary concepts but they lack collaboration between education, research and practice. Lecturers indicate the need for a competence profile for primary care professionals as common framework to guide curriculum development.

Short: With the use of the Rainbowmodel of Valentijn as a guide you will discover how to develop an integrated implementation strategy for goal oriented care across the system as a catalyst for person centered system integration. Why: Health systems are in constant transformation to optimize integrated care delivery for patients with complex needs. One of the suggested strategies for person centered integrated care delivery (PC-IC) is an explicit focus on patients’ personal goals throughout care delivery. This should reorient the focus on disease oriented quality indicators to outcomes that matter to people. To get this focus on patients goals implemented throughout the system, actions in practice, research, and policy are required. An approach that highlights the importance of explicitly starting from the patients' personal goals is goal oriented care (GOC). When we look at the implementation of GOC through the lens of Valentijn's rainbow model we can identify different strategies for sustainable and integrated implementation of this person centered approach. Audience: Everyone with interest in person-centered integrated care and/or goal-oriented care and anyone on how this approach can be supported and adopted throughout the system. Structure Introduction 20’ Group work 35’ Plenary discussion 25’ Wrap up and key messages 15’ How to engage The workshop will start with a short introduction on why GOC could serve as a catalyst for person-centered system integration. Consequently the speakers will walk the group through the different levels (arcs) of Valentijn's model for integrated care showing examples of how different GOC projects in research, practice, teaching and policy are conducted at the different levels and how they focus on functional and/or normative integration. Next, the group will be divided in small groups who each will focus on a separate arc from the rainbow model (the citizen/patient/informal caregivers level, the providers/clinical level, the interprofessional team level, the organizational level and the policy level) A moderator will facilitate a group discussion about how GOC could be supported at that specific level and how. The rainbow model will act as a visual aid and will be used as a surface for post-it notes, to further facilitate interaction. After the brainstorm in small groups, the ideas from the different arcs will be reported back in a plenary discussion. The discussion will serve as inspiration to help participants think about how they can support the implementation of GOC (or other concepts) starting from their individual context and position &amp; to see how initiatives at different levels also mutually reinforce each other. How are you going to summarize the take home messages? Following the group discussion, four junior GOC researchers will report on the lessons they have learned throughout the workshop, using the rainbow model as a guide. They will reflect on how the group discussions resonate with their own research and how the group’s reflection created perspectives for future research and implementation work both at the local and at the international level.

Toward a Theory of Behaviour Change in Social Marketing

Introduction: The policy shift towards stronger primary care systems increases the interest in primary care within different training programs. Implementing new evidence about primary care into education, could be supportive for more integrated and person-centered care. Hence, it could also support the capacity building for integrated primary care. Therefore, the aim of this study is to research if and how lecturers implement new evidence in the curricula and what they need for a successful integrated implementation. Method: Thirty three lecturers representing a variety of Flemish higher education healthcare curricula participated in eleven focus groups. Focus groups were organized in two stages and participants were expected to attend both of them. A first stage was about the current state of affairs (e.g. to what extent and how primary care is present in their curricula). The second stage was about how lecturers want to be supported to implement new evidence in their programs. Results: Despite that all participants indicated that primary care was already present in their curricula they described a lack of knowledge on how and where it was embedded. Nor where they aware of the presence of a vision on primary care education. They felt a lack of collaboration between the different programs, interprofessional integration and interorganizational integration. Moreover, they indicated that they felt the need for a competence profile for primary care professionals as common framework to guide curriculum development. They need clearly defined competences to define the learning objectives on primary care topics of their training programs. The focus groups suggested the model of the T-shaped professional. A T-shaped professional has the expertise in his own field and the ability to apply knowledge in areas of expertise other than one's own and foster collaboration across disciplines. Given the rise of new evidence in healthcare, such as goal-oriented care, self-management and interprofessional collaboration, participants indicated that it was difficult to select concepts that are worthwhile to invest in. They reported that they expect researchers to identify those concepts that need to be sustainably implemented in the training programs of health and welfare professionals. They wanted researchers to translate the scientific results into ‘building blocks’ that could easily be integrated into their curricula, including evidence based content but also materials with suggestions for didactic formats (e.g. course preparation with learning outcomes, presentations, web lecture…). Depending on the learning objectives lecturers want to achieve, they could choose a particular building block. Discussion and conclusion: Lecturers are eager to implement new evidence but they lack an overall vision and a competency framework. There is potential for implementing new concepts, when these concepts are translated in building blocks that could be integrated in the curricula. Furthermore, a T shaped competency profile for person centered primary care could support more collaboration between professionals and lead to more integrated care. Results indicate the need for more collaboration and integration between research, education and practice. The Primary Care Academy could play a role in the co-creation of educational development and its implementation.

Background: The healthcare system is faced by an increase in chronic conditions and multimorbidity. People with chronic conditions (i.e., ‘patients’) are often confronted with an overload of tasks (e.g., medication management, control visits) prescribed by multiple providers to manage their conditions. As a result, they are at risk of fragmented care. A strategy to integrate the different processes might be to explicitly focus on the patients’ personal goals. Goal-oriented care (GOC) reorients care from ‘what is the matter with the patient’ to ‘what matters to the patient’ and specifically addresses patients’ personal goals. However, little is known about GOC. Especially about whether and how patients experience GOC during their primary care visits. The aim of this study is to understand the concept of GOC through the patients’ experiences. Method: Interviews with people with chronic conditions (n=50) were analyzed in two ways. A deductive approach based on the GOC attributes generated in a concept analysis on GOC: goal-elicitation, goal-setting, goal-evaluation, patients’ context, and patients’ needs and preferences. An inductive approach based on a thematic analysis using descriptive phenomenology to identify additional aspects of GOC. Results: The phase of goal-elicitation was recognized by participants, whereas goal-setting and goal-evaluation were experienced in lesser extent. Regarding the underpinning attributes, mixed feelings were reported concerning the integration of the patients’ context and the presence of their needs and preferences throughout the care process. The inductive analysis revealed specific attention to informing patients about their condition and treatment options and discussing goals in interprofessional collaboration. Conclusion: Goal-elicitation was already present and seems to be a good foundation for GOC. More attention should be given to goal-setting and goal-evaluation. Developing guidance by means of a workflow, tools, or questions might support people with chronic conditions and providers to underpin the entire care process with the patients’ personal goals.

BackgroundChronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired.MethodsSix literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC.ResultsFour guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired.ConclusionThis review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.

To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium. GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice. PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work. The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

Diet and Physical Activity to Prevent Recurrence of High Risk Adenomas: A feasibility study

AimDeveloping a theory explaining how public health nurses accomplish and adapt counselling in lifestyle habits to decrease obesity in people with mobility disability.DesignEmpirical research ‐ qualitative.MethodClassic grounded theory with face‐to‐face interviews, 2017–2018, using inductive approach to understand public health nurses' intervening experiences with obesity patients.ResultsTo initiate the conversation emerged as the main concern meaning having difficulties initiating conversations about obesity with patients. Public health nurses’ facilitators to communicate lifestyle changes emerged as the pattern generating the theory, which consists of the categories; person‐centeredness in the situation, experience and knowledge, strengthening conditions, access to other professionals and prioritization in everyday work.ConclusionsPublic health nurses hesitate to raise topics of obesity in patients with mobility disability. They advocate increased integration with lifestyle changes in everyday work including multi‐professional cooperation. The implication is testing the emerged theory at primary health care centres.ImpactObesity is more common in people with mobility disability than in those without. There is a need to understand how public health nurses adapt counselling in lifestyle habits. Public health nurses hesitate to talk about obesity with patients in fear of offending anyone. Public health nurses did not distinguish between patients with or without mobility disability. Several facilitators could be helpful initiating conversation with the patients. Public health nurses need more time and resources to facilitate conversation with patients with mobility disability to counsel lifestyle changes.

Health and Wellness Coaching: An Opportunity for Clinical Exercise Physiologists

BackgroundIndividuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.MethodsUsing principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.ResultsFollowing a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.ConclusionThe CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

BackgroundStudies have shown that lifestyle behavior changes are most effective to prevent onset of diabetes in high-risk patients. Primary care providers are charged with encouraging behavior change among their patients at risk for diabetes, yet the practice environment and training in primary care often do not support effective provider counseling. The goal of this study is to develop an electronic health record-embedded tool to facilitate shared patient-provider goal setting to promote behavioral change and prevent diabetes.MethodsThe ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial leverages an innovative system that integrates evidence-based interventions for behavioral change with already-existing technology to enhance primary care providers' effectiveness to counsel about lifestyle behavior changes. Using principles of behavior change theory, the multidisciplinary design team utilized in-depth interviews and in vivo usability testing to produce a prototype diabetes prevention counseling system embedded in the electronic health record.ResultsThe core element of the tool is a streamlined, shared goal-setting module within the electronic health record system. The team then conducted a series of innovative, "near-live" usability testing simulations to refine the tool and enhance workflow integration. The system also incorporates a pre-encounter survey to elicit patients' behavior-change goals to help tailor patient-provider goal setting during the clinical encounter and to encourage shared decision making. Lastly, the patients interact with a website that collects their longitudinal behavior data and allows them to visualize their progress over time and compare their progress with other study members. The finalized ADAPT system is now being piloted in a small randomized control trial of providers using the system with prediabetes patients over a six-month period.ConclusionsThe ADAPT system combines the influential powers of shared goal setting and feedback, tailoring, modeling, contracting, reminders, and social comparisons to integrate evidence-based behavior-change principles into the electronic health record to maximize provider counseling efficacy during routine primary care clinical encounters. If successful, the ADAPT system may represent an adaptable and scalable technology-enabled behavior-change tool for all primary care providers.Trial RegistrationClinicalTrials.gov Identifier NCT01473654

BackgroundTo address the many challenges health systems and communities face, primary care is constantly searching for new strategies to improve quality of care. One of the strategies is to focus on patients’ personal goals to direct the care process. To adopt an explicit focus on patients’ personal goals, actions at different levels are required. As a first step in this process, this study aims to explore the experiences of primary care stakeholders (i.e., scholars, primary care providers, and policy makers) and develop a comprehensive understanding on the idea ‘putting patients’ goals first’. This will help to formulate suggestions about what these actions should include.MethodIn this study, 41 primary care stakeholders participating in six focus groups between January 2020 and September 2020, were recruited via maximal variation purposive sampling. Data collection was done through an open-ended semi-structured interview guide. Focus groups were audio-recorded, transcribed verbatim, and analyzed following a phenomenological-hermeneutical philosophy of Lindseth and Norberg.ResultsAll participants expressed a strong fundamental belief for putting patients’ personal goals first. The primary care providers shared that they created space for patients’ personal goals by letting them talk about their values and stories. They reported to integrate their medical expertise with patients’ personal goals in order to develop a balanced relationship. In this context, they also talked about the importance of taking into account the perspectives of patients’ significant others. Primary care providers also talked about how they used patients’ personal goals as a guide in interprofessional collaboration. Scholars denoted that (future) care providers need more training to acquire competencies to discuss patients’ personal goals. The providers and policy makers talked about organizational limitations in terms of time restrictions and the lack of registration systems to support a workflow oriented towards patients’ personal goals.ConclusionsThis study can be used to support the coherence of the development of different actions and strategies to get primary care stakeholders fully on board to support the adoption of patients’ personal goals in care delivery at different levels. However, models of practice and policy plans are needed to work towards a person-centered integrated system.