Goal-oriented Care Research Articles

Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial.

The aim of this study was to assess whether coaching doctors to enhance ethical decision-making in teams improves (1) goal-oriented care operationalized via written do-not-intubate and do-not attempt cardiopulmonary resuscitation (DNI-DNACPR) orders in adult patients potentially receiving excessive treatment (PET) during their first hospital stay and (2) the quality of the ethical climate. We carried out a stepped-wedge cluster randomized controlled trial in the medical intensive care unit (ICU) and 9 referring internal medicine departments of Ghent University Hospital between February 2022 and February 2023. Doctors and nurses in charge of hospitalized patients filled out the ethical decision-making climate questionnaire (ethical decision-making climate questionnaire, EDMCQ) before and after the study, and anonymously identified PET via an electronic alert during the entire study period. All departments were randomly assigned to a 4-month coaching. At least one month of coaching was compared to less than one month coaching and usual care. The first primary endpoint was the incidence of written DNI-DNACPR decisions. The second primary endpoint was the EDMCQ before and after the study period.Because clinicians identified less PET than required to detect a difference in written DNI-DNACPR decisions, a post-hoc analysis on the overall population was performed. To reduce type I errors, we further restricted the analysis to one of our predefined secondary endpoints (mortality up to 1year). Of the 442 and 423 clinicians working before and after the study period, respectively 270 (61%) and 261 (61.7%) filled out the EDMCQ. Fifty of the 93 (53.7%) doctors participated in the coaching for a mean (standard deviation [SD]) of 4.36 (2.55) sessions. Of the 7254 patients, 125 (1.7%) were identified as PET, with 16 missing outcome data. Twenty-six of the PET and 624 of the overall population already had a written DNI-DNACPR decision at study entry, resulting in 83 and 6614 patients who were included in the main and post hoc analysis, respectively. The estimated incidence of written DNI-DNACPR decisions in the intervention vs. control arm was, respectively, 29.7% vs. 19.6% (odds ratio 4.24, 95% confidence interval 4.21-4.27; P < 0.001) in PET and 3.4% vs. 1.9% (1.65, 1.12-2.43; P = 0.011) in the overall study population. The estimated mortality at one year was respectively 85% vs. 83.7% (hazard ratio 2.76, 1.26-6.04; P = 0.011) and 14.5% vs. 15.1% (0.89, 0.72-1.09; P = 0.251). The mean difference in EDMCQ before and after the study period was 0.02 points (- 0.18 to 0.23; P = 0.815). This study suggests that coaching doctors regarding ethical decision-making in teams safely improves goal-oriented care operationalized via written DNI-DNACPR decisions in hospitalized patients, however without concomitantly improving the quality of the ethical climate.

Psychosocial Correlates and Behavioral Response to a Carbon Fiber Orthosis and Intensive Rehabilitation Program

Introduction Carbon fiber custom dynamic orthoses (CDOs), a type of ankle-foot orthosis (AFO), have been shown to improve function and mobility. Psychosocial aspects of disability can influence outcomes in prosthetic and orthotic users, but their association with outcomes in CDO users is unknown. Objective The aim of this study was to examine the relationships between physical and psychosocial outcomes following an intensive rehabilitative program including a carbon fiber ankle-foot orthosis, and identify factors related to continued orthosis use. Study Design Retrospective cohort with long-term follow-up. Methods An online survey including questions about device behaviors, self-reported function, pain, global health, self-efficacy, pain interference, resilience, and kinesiophobia was completed by participants who received a custom carbon fiber ankle-foot orthosis and intensive training because of chronic neuromusculoskeletal lower-limb disability. Results The mean follow-up was 4.0 (±1.0) years. Sixty-three adult participants responded to the survey (21 women, 42 men; mean age, 41 ± 12 years). All psychosocial outcomes at follow-up were within “good” or “normal” limits (&lt;1 SD from reference population mean) on average. Strong correlations were observed between self-reported physical function and psychosocial outcomes, and moderate correlations were observed among psychosocial outcomes, between baseline physical outcomes and psychosocial outcomes, and between long-term outcomes and psychosocial outcomes. Device continuation at long-term follow-up was 68%. Conclusions Four years after the intervention, respondents with chronic lower-limb disabilities reported scores that were comparable to normative values for kinesiophobia, health-related quality of life, self-efficacy for managing their condition, pain interference, and psychological resilience. Clinical Relevance Psychosocial variables can affect the outcomes with, and perception of, orthotic devices in individuals with lower-limb neuromusculoskeletal deficits. A goal-oriented care program with emphasis on technique training, postdelivery follow-up, and psychosocial status may help explain long-term outcomes with CDOs and continued device use.

Palliative Pharmacotherapy for Cardiovascular Disease: A Scientific Statement From the American Heart Association.

Cardiovascular disease exacts a heavy toll on health and quality of life and is the leading cause of death among people ≥65 years of age. Although medical, surgical, and device therapies can certainly prolong a life span, disease progression from chronic to advanced to end stage is temporally unpredictable, uncertain, and marked by worsening symptoms that result in recurrent hospitalizations and excessive health care use. Compared with other serious illnesses, medication management that incorporates a palliative approach is underused among individuals with cardiovascular disease. This scientific statement describes palliative pharmacotherapy inclusive of cardiovascular drugs and essential palliative medicines that work synergistically to control symptoms and enhance quality of life. We also summarize and clarify available evidence on the utility of guideline-directed and evidence-based medical therapies in individuals with end-stage heart failure, pulmonary arterial hypertension, coronary heart disease, and other cardiomyopathies while providing clinical considerations for de-escalating or deprescribing. Shared decision-making and goal-oriented care are emphasized and considered quintessential to the iterative process of patient-centered medication management across the spectrum of cardiovascular disease.

Journey Through Healthcare of People With Complications of Type 2 Diabetes: A Qualitative Study of Lived Experiences.

Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases. This study aims to achieve a deeper understanding of how people with complications of a chronic disease - diabetes type 2 - experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis. The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support. Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care.

How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the implementation of goal-oriented primary care

BackgroundAlthough the importance of context in implementation science is not disputed, knowledge about the actual impact of external context variables on implementation processes remains rather fragmented. Current frameworks, models, and studies merely describe macro-level barriers and facilitators, without acknowledging their dynamic character and how they impact and steer implementation. Including organizational theories in implementation frameworks could be a way of tackling this problem. In this study, we therefore investigate how organizational theories can contribute to our understanding of the ways in which external context variables shape implementation processes. We use the implementation process of goal-oriented primary care in Belgium as a case.MethodsA qualitative study using in-depth semi-structured interviews was conducted with actors from a variety of primary care organizations. Data was collected and analyzed with an iterative approach. We assessed the potential of four organizational theories to enrich our understanding of the impact of external context variables on implementation processes. The organizational theories assessed are as follows: institutional theory, resource dependency theory, network theory, and contingency theory. Data analysis was based on a combination of inductive and deductive thematic analysis techniques using NVivo 12.ResultsInstitutional theory helps to understand mechanisms that steer and facilitate the implementation of goal-oriented care through regulatory and policy measures. For example, the Flemish government issued policy for facilitating more integrated, person-centered care by means of newly created institutions, incentives, expectations, and other regulatory factors. The three other organizational theories describe both counteracting or reinforcing mechanisms. The financial system hampers interprofessional collaboration, which is key for GOC. Networks between primary care providers and health and/or social care organizations on the one hand facilitate GOC, while on the other hand, technology to support interprofessional collaboration is lacking. Contingent variables such as the aging population and increasing workload and complexity within primary care create circumstances in which GOC is presented as a possible answer.ConclusionsInsights and propositions that derive from organizational theories can be utilized to expand our knowledge on how external context variables affect implementation processes. These insights can be combined with or integrated into existing implementation frameworks and models to increase their explanatory power.

Models of care in secure services for people with intellectual and developmental disability: Implementing the Walkway to Wellness.

Changes to policy around inpatient services for people with intellectual and developmental disability (IDD) who offend, have led to a need for services to reconsider their models of care. This has led to calls for more tailored, patient-centred care models, with less reliance solely on offence-related treatment programmes which can be unsuitable for a growing proportion of patients with more complex cognitive and behavioural difficulties. In response, the Walkway to Wellness (W2W) was developed at one National Health Service Trust providing secure services to people with IDD, with the intention of delivering a more collaborative, co-produced and goal-oriented care model that was better understood by staff and patient stakeholders. To evaluate the implementation of the W2W using Normalisation Process Theory (NPT), an evidence-based theoretical approach is used across a number of health settings. Staff were invited to complete a short questionnaire, using the NPT informed Normalisation Measure Development questionnaire, at two time points along the implementation process. Patients were invited to complete a simplified questionnaire. Both groups were asked for their views on the W2W and the process of its implementation. Although the W2W was more familiar to staff at the second time point, scores on the four NPT constructs showed a trend for it being less embedded in practice, with significant results concerning the ongoing appraisal of the new model. Patient views were mixed; some saw the benefit of more goal-oriented processes, but others considered it an additional chore hindering their own perceived goals. Early involvement of all stakeholders is required to enhance the understanding of changes to models of care. Live feedback should be used to refine and revise the model to meet the needs of patients, carers and staff members.

Strategies for the implementation of Goal Oriented Care through the lens of Valentijn’s Rainbowmodel for integrated care.

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.&#x0D; 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.&#x0D; 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.&#x0D; Structure&#x0D; Introduction 20’&#x0D; Group work 35’&#x0D; Plenary discussion 25’&#x0D; Wrap up and key messages 15’&#x0D; How to engage&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.

Goal-oriented care through the eyes of people with chronic conditions

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. &#x0D; 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.&#x0D; 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. &#x0D; 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. &#x0D; &#x0D; &#x0D;

In what context does goal-oriented care thrive? A qualitative study investigating how contextual factors influence implementation efforts for goal-oriented care.

This study aims to explore how the concept of goal-oriented care is being picked up and adopted in Flanders, Belgium. Looking at the meso- and macro-level context: what drives the implementation process of goal-oriented care forward and what might hinder its uptake? This research helps individuals and organizations who want to introduce an innovation such as goal-oriented care inside their organization or in the broader primary care landscape by offering insights into an implementation process, in particular on how contextual elements influence implementation efforts. &#x0D; We conducted qualitative research, performing in-depth interviews with n=23 respondents who are involved with the implementation of goal-oriented care within their professional function, either on project level or strategic/policy level. This way, we learned about the perspectives and lived experiences of a wide range of actors working for governmental institutions, non profit organizations, provider organizations, patient organizations, health or social care organizations and care councils. Data were collected using a semi-structured interview guide, audio recorded, and analyzed first inductively and then deductively using a categorization of constructs into structural, organizational, provider, patient, and innovation level factors, as described by Chaudoir et al. (2013). &#x0D; Our preliminary findings suggest that facilitators for the implementation of goal-oriented care are mainly found on an organizational, provider and innovation level. Active commitment, overall recognition of goal-oriented care as quality of care and setting up a form of coordination are key. Most prominent barriers are found on a structural level, which shows that for goal-oriented care to be actually embedded in primary care the meso- and macro context structures and preconditions should be further shaped. &#x0D; Our findings can contribute to further translate the concept of goal-oriented care into a practice-based intervention. It gives insight in how to perform a context scan for a primary care intervention and highlights the dynamics between contextual factors and implementation efforts. The next step is to define implementation strategies for goal-oriented care that come forward out of the identified barriers and facilitators.

Towards more goal-oriented care through care coordination and care planning.

The increasing aging of our society is putting increasing pressure on the current organization of care and support. This moved the Flemish government to a thorough reform of primary care in Flanders. This was started in 2017. The reform involves changes in terms of content, structural support and instrumental support. All these changes should lead to care and support that can be organized using the principles of integrated care and goal-oriented care. The major challenges are: &#x0D; - bring about a change in mentality among care providers toward these principles of integrated care and goal-oriented care;&#x0D; - make a connection between health care and welfare care, as well as between primary care and more specialized care, and align the processes of care and support. &#x0D; In addition, it is necessary to translate the principles of goal-oriented care into practical tools and accelerate methodology development. We are working together with several partners in Flanders for this purpose. &#x0D; In goal-oriented care, an important role is reserved for the care coordinator. The care coordinator is the focal point of the care team who, as a member of the care team, takes on the task of: &#x0D; - maintain an overview of the care process; &#x0D; - ensure that all care and support, determined on the basis of the person's care or support needs and translated into life goals and care and support goals, is coordinated, monitored and evaluated. &#x0D; Care coordination in a care process maintains a focus on goals, both the person's own life goals and the care and support goals of the care team. &#x0D; For implementing qualitative care coordination, the care and support plan is an indispensable tool within the Flemish reform. This care and support plan must: &#x0D; - allow an overview of the sometimes multitude of care and support goals; &#x0D; - be a means of communication between the members of the care team (including the person himself and his informal care); &#x0D; - reflect the extent to which care agreements are met; &#x0D; - allow the care process to be monitored, evaluated and adjusted if necessary. &#x0D; &#x0D; &#x0D; In the near future we want to design this care and support plan in a digital way. &#x0D; The care coordinator must have a wide range of competencies in order to coordinate the care process in a quality manner, including: &#x0D; - mastering to perfection the methodology of goal-oriented care, interview techniques, conflict management, process guidance, process analysis, coordination and organization skills; &#x0D; - being the point of contact for the person with a care and support need; &#x0D; - be able to play the bridge between the person, informal care and professional care providers. &#x0D; In this presentation, we focus on the role of the care coordinator throughout the care process and the planning aspect. We propose how the Flemish government want to develop this role in the future. We also reflect on the preconditions that are necessary to achieve a solid implementation of this role, and indicate what opportunities we see to promote and accelerate the change in mentality in this regard.

Monitoring the governance maturity of network organizations.&amp;nbsp;&amp;nbsp; A session for policymakers.

In 2020 Flanders has installed care councils as a network organization at meso level. The care council aims to install integrated, goal-oriented care within the local network of medical care providers, social and welfare providers and local authorities, in cooperation with the patient and his or her caregiver. Together with all these partners, the care council takes care of a population of at least 75,000 people.&#x0D; In this way, the Flemish government wants to move from a fragmented care system towards integration in which goal-oriented care, based on the life goals of citizens, is central.&#x0D; Care councils were established during the covid years. Within the Flemish healthcare landscape, the fight against the covid-19-pandemic created a great connection between the different partners. This collaboration was enhanced by the work of the brand new care councils. Now that the pandemic is coming under control, new and complex challenges are piling up for these new network organizations:&#x0D; &#x0D; How can the local network be engaged to provide quality, integrated care within their network organizations?&#x0D; Within a decentralized care policy, how can priority-setting be done without compromising global and local policy objectives?&#x0D; How do these young organizations plan to face future crises, together with their networks? How do they increase their resilience?&#x0D; &#x0D; In this workshop, we want to bring policymakers and network organizations from different regions around the table to reflect on how organizations can be followed up in their growth towards managerial maturity. Both the core objective (implementation of integrated, goal-oriented care within the network) and increasing resilience in crisis situations are guiding this. What systems exist for this purpose? What good practice examples are available? Which indicators are suitable? This session mainly aims to explore and take inventory.&#x0D; The workshop will be made up of:&#x0D; &#x0D; 15-minute introduction and context&#x0D; 3 x 15 minutes of work around 3 different themes (exchanging experiences and good practices):&#x0D; a) Measuring and monitoring managerial maturity and good governance of network organizations to achieve integrated, goal-oriented care&#x0D; b) Monitoring and measuring priority setting as a function of different policy objectives from different levels&#x0D; c) Follow up on how organizations increase their resilience in function of various crisis situations.&#x0D; 3 x 5-minute to bundle the results&#x0D;

Goal-oriented care in an integrated care organization

i-mens is the largest integrated care organization in Flanders and Brussels with 12,000 employees serving over 70 000 customers yearly. It provides care through all phases of life, with a wide range of services. Providing Goal-Oriented Care is inherently part of the vision of i-mens. However, a clear and standardized opproach is lacking. &#x0D; By implementing a new framework, a transparent approach is created to help our customers in an equitable way, while keeping into account that everyone has different life goals/needs. &#x0D; At the beginning of 2022 i-mens started a process, with the support of the King Baudouin Foundation and in collaboration with Steunpunt Mantelzorg, to implement GOC within the organization. The new methodology is to be evaluated by the persons with a care and support needs, our internal staff, as well informal caregivers. i-mens believes it is important to involve the informal caregiver, because they guarantee continuity of care when the professional support ends. European research shows that 80% of long-term care is provided by informal caregivers.&#x0D; During ICIC23 we wish to highlight the following topics: The choice of methodology based on the following parameters: There are various methods of GOC in Flanders. These methods were evaluated on the parameters: ‘understandable’, ‘personal input’, ‘time investment’, usable in their context, etc. We opted for 2 possible methods. These methodologies were presented to a test audience (focus groups).&#x0D; The survey from the focus groups: During autumn 2022, we organized three focus groups: clients, informal caregivers and our employees. The two chosen methodologies were presented to a test audience. Based on their findings, we opted for one methodology.&#x0D; The testings: After the decision has been made about the chosen methodology, we are going to start the implementation (spring 2023). Employees initiate the methodology in collaboration with the client and their informal caregiver. &#x0D; In a later stage, this methodology will be used as a guideline during multidisciplinary meetings where various stakeholders (general practitioners, home nurses and other primary care actors) participate.&#x0D; The target audience: The GOC-methodology is aimed at every customer, but due to practical and efficiency reasons we initially focused on the customer living at home. During the presentation, their findings will be communicated.&#x0D; Challenges: Whitin this topic we explain the various challenges that we encounter along the way: rethinking of the customer, informal caregiver (empowerment), external primary actors and the internal employees.&#x0D; However it should be stressed that besides choosing a methodology, the basic attitude of professional caregivers plays a key role as well in achieving a successful Goal-Oriented Care. Both elements form the basis of Goal-Oriented Care as you cannot have the one without the other. Since autumn 2022, we have been communicating about GOC to all our 12,000 employees through (digital) newsletters, conversations with the training department, organizing information moments, etc.

Why and how Flanders wants to roll out goal-oriented, integrated care based on life goals.&amp;nbsp; A reflection between policymakers and policy organizations.

Flanders believes that integrated care can only be achieved by linking medical care, with welfare and social care, creating local government participation and including the voice of the patient and his or her caregiver in local and central policy processes. &#x0D; In order to evolve from fragmented primary care to integrated care, a participatory procedure was mapped out in Flanders: since 2020 existing structures were changed and several tools have been developed to transform the way of care into goal oriented care. &#x0D; The Flemish meso level was thoroughly rearranged: during the covid years population-based approach was rolled out by local care councils. The care council aims to install integrated, goal-oriented care within the local network of medical care providers, social and welfare providers and local authorities, in cooperation with the patient and his or her caregiver. Together with all these partners, the care council takes care of a population of at least 75,000 people.Finally primary care, and by extension the entire care scene, will evolve towards better goal-oriented, integrated care. This evolution is supported by the implementation of the digital care and support plan which is flanked by a the reform traject of palliative care in Flanders,&#x0D; The main goal of in Flanders care organization is putting the patient in the driving seat of the care-process which will be based on life goals&#x0D; For policymakers and organizations, this presentation aims to look back at the complex change process, outline future challenges and share lessons learned.&#x0D; We show how strategically chosen change management creates connection between welfare, social and medical care. How, the interaction between patient and caregivers and local authorities try to achieve integrated care in the local communities&#x0D; We show our complex challenge of introducing quality thinking and building organizational resilience for future crises within the young care council.&#x0D; We discuss the complexity of linking local priorities with global policy objectives and vice versa.

TransForm – Integrated Community Care (ICC) from aspiration to reality

Introduction: As we face crises after crises (climate, geopolitical, health, financial), each one increasing inequalities and impacting most on people and communities in vulnerable situations, we need to come up with better ways of living and caring for people and the planet. Most challenges we face today are complex and interrelated and to solve them requires participation from communities and citizens.&#x0D; As part of this, the mere concept of care needs to be redefined towards a social capacity and activity involving the nurturing of all that is necessary for the welfare and flourishing of life. The current system of care was designed in and for the industrial era and it has reached the limits of what it can achieve. Today’s diseases are chronic and complex and require different responses. We need to reimagine and create a system designed for the problems we face today. &#x0D; Integrated Community Care (ICC) is a concept that has evolved and is based on a range of important innovations and efforts in the field, such as people centred care, community primary care, integrated care, social determinants of health, goal-oriented care, amongst others. ICC acknowledges that each of these, although important, are not enough on their own and brings them together. In ICC, local organizations, community members, professionals, and policy makers come together in a continuous process of co-developing health, care and social support infrastructures to enhance the quality of life, social cohesion and resilience of a territorially defined community. It is not a prescriptive approach, but rather a set of principles that guide a range of existing practices that are changing the way health and care are organised.&#x0D; Aim: to inspire and better equip policy makers and practitioners to make ICC the new norm by sharing learnings and experiences of the TransForm community, including defining what ICC is, its benefits and demonstrating how to put the theory into practice.&#x0D; Audience: Citizens, policy makers, practitioners, academics that realise that the multiple crises we face are an opportunity to create something better. It is for anyone seeking for more effective ways to truly care for, about and with people and communities. &#x0D; Who did we involve and what we did? &#x0D; Since 2018, through a series of research activities, international conferences, site visits to ICC initiatives, workshops among experts, activities within a Changemakers Forum, TransForm has developed a learning journey (co-production of knowledge with stakeholders – academics, policymakers, decisionmakers, practitioners, people with lived experience, citizens) that has identified key values – ingredients – challenges- for ICC. An important part of this learning journey is the contribution of ICC changemakers, investing in locally anchored innovation and making the difference again and again in the daily lives of people.&#x0D; What are the next steps? TransForm will create an open-source collection of knowledge on ICC.&#x0D;

Building a digital care and support plan: research as a starting point. A session for policymakers.

In 2018, the idea arose of building a digital care and support plan for primary care. The research on life goals and care goals during the COVID years allowed us to clarify informed choices in the ICT specifications and digital development can start in 2023.&#x0D; The reform of the primary care in Flanders envisioned a digital capstone. Therefore, a business analysis for a digital care and support plan was prepared in 2018. This digital care plan should:&#x0D; * facilitate goal-oriented and integrated care, &#x0D; * give individuals with care and support needs control over their care planning, and &#x0D; * allow care providers to collaborate interdisciplinary and coordinate their care within the care team. &#x0D; The scope and associated resources were largely lacking at that time, and the subsequent COVID crisis prevented the project from even starting at all. &#x0D; We used this pause to engage academia. We asked them what goal-oriented care might look like in practice: &#x0D; * How do you integrate life goals into care planning? &#x0D; * Can you create links between life goals and care goals?&#x0D; * In what ways can you link care goals to existing care scales? &#x0D; The researchers' recommendations to these questions, gave us a clearer view of the possibilities and scope of our project. This information helped us to:&#x0D; * Write a clearer ICT specification&#x0D; * Clearly define the functional requirements&#x0D; * Propose an evidence-based approach to stakeholders&#x0D; * Prioritize the different digital modules to be developed&#x0D; * Engaging academics in a technical debate&#x0D; Do not underestimate the impact of sound research. Do not rush into an ICT project without fundamentally questioning the content and scope of the project. Consult academics who will work out the concepts in a research context with people in the field. Then build on this input.&#x0D; The inputs from the research questions are currently being used as a starting point for the digital modules on life goals and care goals. These modules are now being further refined with stakeholders and will serve as a starting point for ICT development this year.

Integrated primary care in higher education, a qualitative study about the needs and preferences of lecturers to implement new evidence.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.

Towards goal-oriented care with Goal Finder

Background: The last decade we have witnessed an increased attention for goal oriented care. Goal oriented care is even considered to be the gateway to integrated care. The aim of goal oriented care is to provide care based on life goals of individuals. Individuals with one or more chronic disease(s) support this shift towards goal oriented care. Their everyday experiences show that a chronic disease has an impact on various aspects of life: care, relationships, insurances, employment,… To be able to increase patients’ quality of life and to provide tailored care it is important to take into account individuals’ life goals, values and norms. While most patients as well as caregivers agree that goal oriented care is the way to go, several barriers to bring goal oriented care into practice are encountered. As such, patients experience difficulties in mapping their life goals and communicating them to their (informal) caregivers. Care givers do not always know how they can take life goals into account when providing care. &#x0D; Aim: To overcome the barriers of patients and caregivers, the Flemish Patient Platform vzw (VPP) has, in cocreation with patients, caregivers and researchers and with support from the flemish government, developed a tool named Goal Finder.&#x0D; Method: Goal Finder enables patients to map their life goals and communicate them towards their family, friends and caregivers. Goal Finder has been tested by patients and caregivers around Flanders. 54 patients and 39 caregivers completed a survey to share their experiences on the tool. Based on the insights a new version of the tool was developed. The VPP applies various dissemination strategies. One way to get acqainted with Goal Finder is through patient organisations (members of VPP). Pain Point, a patient organisation for patients with chronic pain, has taken several actions to disseminate the tool and bring goal oriented care into practice. As such, they organised a webinar on how to use Goal Finder, contacts between peers to share experiences on goal oriented care and Goal Finder and two symposia aiming to motivate patients and caregivers to bring goal oriented care into practice.&#x0D; Results: The study of VPP as well as the experiences of Pain Point show that Goal Finder has an added value for various patients and caregivers. As such, the tool increases patient participation and enables a more equal relationship between patients and caregivers. When care is goal oriented the motivation of patients increases as well.&#x0D; Conclusion: To fulfill the promise of goal oriented care as gateway to integrated care we should continue to disseminate tools such as Goal Finder and inform patients as well as caregivers on how to bring goal oriented care into practice.&#x0D;

How do I roll out a digital collaboration tool?

In 2023, the Flemish government will start developing a digital care and support plan. With this shared support plan, we want care providers, informal caregivers and citizens to collaborate digitally in a goal-oriented care plan. &#x0D; The digital care and support plan is being built by an external IT partner in co-creation with stakeholders and citizens. In a first test version, 5 modules are offered: &#x0D; * Communication &#x0D; * Life goals &#x0D; * Care and support goals &#x0D; * Care and support tasks &#x0D; * Care team &#x0D; After a test phase at the end of 2023 this digital collaboration tool will be rolled out across Flanders in two pilot projects. &#x0D; The rollout will be planned on 3 axes (possibly in parallel): &#x0D; * geographical extension: step by step connecting a number of new zones&#x0D; * multidisciplinary expansion: integrate new sectors step by step &#x0D; * substantive expansion: develop additional modules &#x0D; In this workshop we will bring policy makers and network organizations from different regions together to share best practices. &#x0D; * What good practices are available? &#x0D; * What is needed to successfully address the 3 axes? &#x0D; * What are the pros and cons of expanding on any of the 3 axes? &#x0D; * What is the impact of each extension on the success of the full rollout? &#x0D; * What is the impact on support and adoption in the field? &#x0D; This session primarily aims to share experiences and bring together knowledge. &#x0D; &#x0D; &#x0D; The workshop will be composed of: &#x0D; * 15 minutes introduction and context &#x0D; * 3 x 10 minutes working around 3 different axes and their impact (sharing experiences and good practices). Naming pros and cons of each axis. &#x0D; * 15 minutes: Distill best approach per group - what order, possibly parallel rollout is preferable? &#x0D; * 15 minutes: combine results into a global best practice

Implementing goal-oriented care and life goals in social services

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.&#x0D; 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.&#x0D; 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.

Protocol for a cluster randomised trial of a goal-oriented care approach for multimorbidity patients supported by a digital platform

IntroductionHealth information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this...