Goal‐based care: engaging individuals in identifying and attaining outcomes that matter
What are best practices for eliciting goals of persons with multiple chronic conditions and identifying outcomes that matter most? How can we best ensure that these goals and outcomes are documented, accessible to, and used by the range of care providers involved in developing and implementing care plans? How can alignment of goals between clinician and patient be ensured systematically? What are strategies to enable comparable measurement of goals and outcomes across different interventions and populations?
Barriers to engagement for persons with MCC
Systems‐based structural change and attention to design
How do system‐level and community‐level factors affect engagement in clinical encounters? How do system‐ and community‐level factors support or impede individual engagement (e.g., user‐friendly technology interfaces, reducing the fragmentation of care, using uniform and clear language)? How do system‐ and community‐level factors support or impede clinicians' ability to foster engagement (e.g., incentives, appointment lengths, education, and formalized roles such as comprehensivists as proposed by Tinetti, Fried, and Boyd
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or intensive outpatient care specialists, with formal fellowship training as such, as recently described by Epstein and Wu
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)? What structural changes, if any, overcome the intention–behavior gap as suggested by Nease et al.?
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Engagement of family members and friends
What is the role of family/friends in engagement with health and health care for persons with MCC? How can engagement of family be intervened upon in a manner that is purposeful and constructive? What structural, systems, and policy‐level elements affect family engagement? What are the essential elements that should be reported in interventions involving friends and family to ensure comparability and implementation fidelity?
Trade‐offs between benefits and unintentional costs of engagement
What safeguards need to be put in place to ensure that a focus on engagement does not unintentionally further marginalize or burden vulnerable populations, including those with multiple chronic conditions? How do structural changes that seek to promote engagement affect vulnerable populations? What strategies will ensure that the absence of evidence of negative effects of engagement interventions is not interpreted as the lack of effect? How do we engage vulnerable (including those with MCC) or hard‐to‐engage populations in research about engagement and to guide implementation of engagement interventions?
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