Operationalizing the Chronic Care Model with Goal-Oriented Care

Agnes Grudniewicz (), Carolyn Steele Gray (), Pauline Boeckxstaens (), Jan Maeseneer () and James Mold ()
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Agnes Grudniewicz: University of Ottawa
Carolyn Steele Gray: Lunenfeld-Tanenbaum Research Institute, Sinai Health
Pauline Boeckxstaens: Ghent University
Jan Maeseneer: Ghent University
James Mold: University of Oklahoma

The Patient: Patient-Centered Outcomes Research, 2023, vol. 16, issue 6, No 1, 569-578

Abstract: Abstract The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person’s goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Date: 2023
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DOI: 10.1007/s40271-023-00645-8

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