Person-Centered, Goal-Oriented Care Helped My Patients Improve Their Quality of Life.

When the goal is to help patients improve their quality of life, it makes sense to focus directly on the activities and relationships that are most important to each patient. This can be accomplished most effectively by following a three-step process that includes 1) connecting with the patient around what matters to them, 2) co-creating a goal-oriented plan, and 3) collaborating with patient, family, team members, and consultants to increase the probability of success. Once this approach has been mastered and the necessary systems, processes, and relationships are in place, this should not take more time than a problem-oriented approach, and it will almost certainly be more satisfying for both physician and patient. The impact on population-based quality metrics is uncertain. Though fewer patients may choose to follow standard recommendations, those who do may be more likely to adhere to them.

Goal setting among older adults starting mobile health cardiac rehabilitation in the RESILIENT trial.

BACKGROUND: There is growing recognition that healthcare should align with individuals' health priorities; however, these priorities remain undefined, especially among older adults. The Rehabilitation Using Mobile Health for Older Adults with Ischemic Heart Disease in the Home Setting (RESILIENT) trial, designed to test the efficacy of mobile health cardiac rehabilitation (mHealth-CR) in an older cohort, also measures the attainment of participant-defined health outcome goals as a prespecified secondary endpoint. This study aimed to characterize the health priorities of older adults with ischemic heart disease (IHD) using goal attainment scaling-a technique for measuring individualized goal achievement-in a sample of 100 RESILIENT participants. METHODS: The ongoing RESILIENT trial randomizes patients aged ≥65 years with IHD (defined as hospitalization for acute coronary syndrome and/or coronary revascularization), to receive mHealth-CR or usual care. For the current study, we qualitatively coded baseline goal attainment scales from randomly selected batches of 20 participants to identify participants' cardiac rehabilitation outcome goals and their perceptions of barriers and action plans for goal attainment. We used a deductive framework (i.e., 4 value categories from Patient Priorities Care) and inductive approaches to code and analyze interviews until thematic saturation. RESULTS: This sample of 100 older adults set diverse health outcome goals. Most (54.6%) prioritized physical activity, fewer (17.1%) identified symptom management, fewer still (13.7%) prioritized health metrics, mostly comprised of weight loss goals (10.3%), and the fewest (<4%) were related to clinical metrics such as reducing cholesterol or preventing hospital readmission. Participants anticipated extrinsic (access to places to exercise, time) and intrinsic (non-cardiac pain, motivation) barriers. Action plans detailed strategies for exercise, motivation, accountability, and overcoming time constraints. CONCLUSIONS: Using goal attainment scaling, we elicited specific and measurable goals among older adults with IHD beginning cardiac rehabilitation. Priorities were predominantly functional, diverging from clinical metrics emphasized by clinicians and healthcare systems.

An age-friendly approach to primary care in an academic health system.

BACKGROUND: Age-friendly care, addressing what matters most, medications, mentation, and mobility, is a successful model for improving older adult care. We describe the initial outcomes of age-friendly care implementation in five primary care clinics in an academic health system. METHODS: In partnership with a regional quality improvement (QI) organization, we used practice facilitation to implement age-friendly care from July 2020 to June 2023. Clinic workflows and electronic health record (EHR) templates were modified to capture six QI measures for patients ≥65 years: Documenting what matters most to patients Advance care planning (ACP) Annual cognitive screening Caregiver referral to dementia community resources Fall-risk screening Co-prescription of opioid and sedative-hypnotic drugs Providers were alerted if patients had positive screens and given support tools for clinical decision-making. QI measures from January-June 2023 were compared to the year prior to implementation. Providers and staff were interviewed about implementation barriers and facilitators. RESULTS: All six measures improved in Geriatrics and and other clinics showed improvement in ACP and cognitive screening. All clinics had high fall-risk screening rates (≥85%). The least improved measure was co-prescription of opioids and sedative-hypnotics with co-prescription rates ranging from 7% to 39%. Implementation hinged on leadership prioritization, practice facilitator guidance, clinical team buy-in, EHR functionality, and clinical performance review. Three clinics received Age-Friendly Health System recognition. CONCLUSIONS: A QI approach using practice facilitation and EHR templates improved some but not all age-friendly care measures. Future interventions will focus on training in high-risk medication tapering and elicitation of health goals.