Abstract
Introduction:Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. 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.Description: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.Discussion:The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care.Lessons learned:By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift.
Highlights
Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide
This paper argues that, goal-oriented care (GOC) offers such an approach
International Cases of Goal-Oriented Care Clinical and professional integration in Ontario, Canada GOC was introduced at a Community Health Centre (CHC) in Ontario, Canada through two programs aimed to improve care for patients with complex health and social needs
Summary
Background At the heart of the World Health Organization’s definition of integrated service delivery lies the aim that “integrated care should be centred on the needs of individuals, their families and communities” [1, p.4]. International Cases of Goal-Oriented Care Clinical and professional integration in Ontario, Canada GOC was introduced at a Community Health Centre (CHC) in Ontario, Canada through two programs aimed to improve care for patients with complex health and social needs. Though there was no explicit push for GOC in the medical clinic or social services teams, it appeared that there was some diffusion of the approach through the Health Links and seniors outreach programs This was only successful where professionals on a patient’s care team all ‘bought in’ to GOC and the use of the care plan. At an organizational level, focusing on client goals enabled identification of which organizations and providers needed to be involved in the Community Health Team to provide necessary ‘wrap around’ services to clients For this case, these organizations included the local hospital, 3 primary care centres, community seniors care agency, housing support, and a mental health agency. In close collaboration with different stakeholders at the micro, meso and macro level, the Academy aims to develop roadmaps and handson toolkits for primary care policies, practice and education, using GOC as a means to advance person-centered integrated care from a system level
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