Goal Attainment Scaling (GAS) in geriatric primary care: A feasibility study
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.
Section snippets
Design
Using a single group, repeated measures design, this study evaluated the ability of community-dwelling older adults with multiple chronic health conditions to use GAS to identify realistic and achievable personal goals, set specific criteria levels for attainment of these goals, and rate their performance of those goals over time.
Participants and setting
Prospective participants were recruited over a six month period through the University of Pittsburgh Medical Center (UPMC) Benedum Geriatric Center (BGC) by their
Results
Of the 28 potential participants who met inclusion criteria, 27 patients consented to participate. While all participants were offered the choice of being seen at home or at the primary care clinic, all participants chose to be seen in their homes. On average, baseline assessments required 1.5 h of the assessor's time to complete all components of assessment and documentation. Follow-up assessments required an average of 45 min to complete. Travel time ranged from 15 min to 60 min (roundtrip)
Discussion
With both a recruitment and goal setting success rate of over 90%, our results suggest that GAS is a feasible tool for generating patient-centered goals with community-dwelling older adults recruited through primary care. Older adults who have multiple, chronic medical and psychiatric health conditions can identify and set realistic and achievable personal goals through GAS. Additionally, our results demonstrate a significant improvement in goal attainment from baseline to follow-up. Such
Conclusion
Primary care has become the preferred setting for chronic disease management. Patient-centered care shows promise for changing the current practice paradigm in geriatric primary care, and collaborative goal setting serves as the foundation for this transformation. Results of our study suggest that community-dwelling older adults diagnosed with complex, chronic health conditions can set personal goals using GAS and can work toward achieving them. The success of goal setting and goal attainment
Competing interests
None declared.
Funding
This work was supported by a pilot seed grant from the Aging Institute of UPMC Senior Services and the University of Pittsburgh.
Acknowledgments
We would like to thank the University of Pittsburgh Medical Center (UPMC) Benedum Geriatric Center physicians and staff for their support in recruitment and goal evaluation for this study.
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