Goal Attainment Scaling (GAS) in geriatric primary care: A feasibility study

Highlights

• Older adults with chronic conditions can set meaningful goals using GAS.

• The process of personal goal setting itself may facilitate goal attainment in older adults.

• GAS is tool that is feasible for use in geriatric primary care.

• GAS can facilitate a patient-centered approach to care with older adults.

Abstract

Objective

Evaluate the feasibility of generating patient-centered goals using GAS with older adults who have multiple chronic conditions, recruited through primary care.

Method

Adults age 65+ (N = 27) were recruited from a geriatric primary care center. Participants were asked to identify 2–4 activity-based goals and set attainment levels using GAS. At 8 weeks, participants were asked to rate current level of their goal performance. Physician surveys were used to evaluate if goals were realistic and feasible, and patient surveys were implemented to evaluate satisfaction. GAS T-scores were used to quantify change in goal achievement.

Results

Ninety-three percent (n = 25) of participants were able to establish a minimum of two goals using GAS. 100% of participants were able to rate goal performance at follow-up. Physician survey results identified 100% of goals realistic and 93% achievable and 100% of participants were either neutral or satisfied with the process. Significant improvement was reported in GAS change scores (t(24) = 6.54, p < 0.001).

Conclusion

Findings support the feasibility of GAS for older adults with multiple chronic conditions in geriatric primary care as a strategy to facilitate patient-centered care and suggest that the process of personalized goal-setting itself may facilitate goal attainment.

Introduction

The clinical management of older adults with multiple chronic conditions is a costly challenge in geriatric care (Bodenheimer et al., 2002, Vogeli et al., 2007). Chronic disease management accounts for 93% of the medical expenditures attributed to older adults, with 25% of those costs incurred by older adults who have five or more chronic conditions (Chi, Lee, & Wu, 2011). With an expanding population of older adults stretching financial and clinical healthcare resources, improved strategies for managing chronic conditions, particularly in primary care, are critical (Boult et al., 2009). Patient-centered care models may pose a solution to this impending crisis (Reuben & Tinetti, 2012). Long recognized as an aim for improved healthcare by the Institute of Medicine (2001), patient-centered care augments the traditional single disease, symptom-driven approach by focusing on the impact of these symptoms on the patient's everyday life. In doing so, patient-centered care still addresses the symptoms, but in a way that increases patient engagement, motivation, and satisfaction while simultaneously reducing costs (Bodenheimer et al., 2002, Leff et al., 2009).

The Patient Protection and Affordable Care Act (2010), the largest and most broad sweeping healthcare legislation recently enacted in the United States, mandates patient engagement and shared decision-making as tenets of quality care (James, 2013). Patient engagement is anchored through the development of goals that are defined by the patient and frequently address everyday needs (Schulman-Green, Naik, Bradley, McCorkle, & Bogardus, 2006). Patient-centered goals improve provider–patient communication by producing collaborative or “shared” priorities between patients and their healthcare providers. Shared priorities present several advantages including a focus on outcomes that span more than one chronic condition, shared expectations for health and function, and more efficient resource utilization (Carroll, 2011, Reuben and Tinetti, 2012, Unutzer et al., 2002). The process of setting goals is often a motivation in and of itself for executing effort toward achieving those goals (Hurn et al., 2006, Locke and Latham, 2002). Despite these benefits, however, older adults are less likely to participate in shared clinical decision making (Schulman-Green et al., 2006).

GAS is a valid and reliable tool for setting quantifiable patient-centered goals, measuring improvement toward these goals, and facilitating communication of shared priorities between patient and provider (Kirusek and Sherman, 1968, Ottenbacher and Cusick, 1990). The potential value of GAS is dependent on the ability to repeat administration of the method over time. These repeated measures generate patient-centered outcomes that not only demonstrate a change in health and function, but can be scaled to allow for comparison of change within and between groups of older adults with distinct personalized goals (Kiresuk, Smith, & Cardillo, 1994). Initially established for use in mental health, GAS has been used effectively as an outcome measure with older adults in multiple settings (Bouwens et al., 2008, Davis and White, 2008, Hurn et al., 2006). However, the feasibility of collaborative goal setting using GAS to increase patient engagement with medically complex older adults through primary care has not been assessed (Bodenheimer & Handley, 2009). Our primary aim was to determine the feasibility of generating patient-centered goals using GAS with community-dwelling older adults who have multiple, chronic conditions, recruited through geriatric primary care. Feasibility would be determined by recruitment effort, and the number of participants able to identify, set, and rate personal goals related to daily living using GAS. Additional aims were to explore how the process of personalized goal setting using GAS impacts goal achievement and to examine the associations between GAS outcomes and select patient characteristics.