Implementing goal-oriented care and life goals in social services

Abstract

Caregivers predominately focus on providing qualitative and appropriate care to patients, with little explicit focus on the patient’s life goals. Although, these life goals should be used as important basis of a care process, regardless someone’s (chronic) condition. It’s the goal of the social services of the Flemish mutuals (diensten maatschappelijk werk van de ziekenfondsen, DMW) to pay specific attention to the life goals of their clients in order to align someone’s care process to what really matters to the client. One way to make this possible is to implement the concept and principles of goal-oriented care in their daily work. To this end, the social services of the mutuals are engaged as early adopters in a co-creation project of VIVEL (Flemish institute of Primary Care) and an implementation project funded by the King Baudouin foundation. It is important for the client that all caregivers, not solely social services, are using this approach to further deepen integrated care. Creating shared values/vision and enabling patients as partners (person-centred care), this approach facilitates integrated care that also takes in to account the life goals of the client.
 With this abstract we are proposing to offer a workshop on the topic of goal-oriented care in Flanders with the purpose to give more insight to care providers both from Flanders and abroad in the concrete implementation of this concept within the social services of the mutuals. After setting the scene with a short theoretical part, we want to directly dive in to practice, focusing on supporting persons with disabilities. We will be presenting real live cases in which we want to explore both care and life goals using recently developed instruments, together with VIVEL, based on the common basic attitude typical of goal-oriented care. After exploring his/her care and life goals, we will start to bring together a care and support plan in which all (needed) care providers are involved. After this, the co-created plan will be followed up, discussed in the care team (which definitely includes the patient and its informal carers) and adapted if needed in time.
 At the end of the workshop we want to sum up the lessons learned from this cases in relation to the complex Belgian reality of implementation processes of interlinked (care) concepts, such as the interRAI instruments and the set-up of a digital care and support plan. Although complex, it is increasingly important to link these concepts, since it has been shown that these initiatives can be useful for linking care and life goals together. Furthermore, we want to answer the question why and how we need to implement goal-oriented care into care planning and providing. We hope to inspire the international integrated care community with this concept being implemented, tested and monitored at the moment, but also to hear learnings from international peers. We hope to further implement this concept in the next months and evaluate its added value to quality of care for the clients and increased job-satisfaction for the collaborators.