Operationalizing the Chronic Care Model with Goal-Oriented Care

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.

Automated summary

The Chronic Care Model has been in place for almost 20 years to improve health care quality using a patient-centered, disease management approach. To enhance person-centered care, the goal-oriented care approach is proposed. This approach focuses on the individual's goals and involves collaborative decision-making between clinicians and patients. This paper builds upon the elements of the Chronic Care Model and provides clinical examples on how to implement goal-oriented care, particularly in the context of multi-morbidity.