Patient Goal Setting: How Should Care Coordinators Help?

It’s no secret that health care in Ontario is becoming more patient-centred. The province’s action plan for health care, Patient’s First, was enacted in 2015. In the time since, a significant shift has occurred. Now more than ever before, people are at the centre of the care they receive.

What does that mean? For many, “patient-centred” sounds like yet another health care buzzword. But those who work tirelessly in the sector know better.

Putting a patient at the forefront of her care means looking at each step in her health care journey—from her point of view. It means respecting her wishes and medical preferences. And if you’re a care coordinator, it also means helping her set her own health care goals.

Patient goal setting is a big part of a care coordinator’s job. But it isn’t always easy. At different times during the goal setting process, you have to take on various roles. Translator. Educator. Advisor.

Helping patients set realistic objectives that they’re actually motivated to achieve is difficult job. But it can also be very satisfying.

In this post, we’ll look at some of the challenges associated with patient goal setting—and how to overcome them.

Listen Actively

It goes without saying that listening is one of the keys to understanding—and to serving others well. It’s also an important part of care planning, a crucial piece of which is patient goal setting.

As a care coordinator, you’ve engaged in clear and productive communication throughout your career. But developing listening skills is a lifelong pursuit—especially in health care. Truly hearing a patient is about more than absorbing information. It’s about listening for the specific information that will help you create a dialog.

As much as possible, you want to align a patient’s goals with his wishes and preferences. The best way to do this isn’t always through a direct question and answer format. Sometimes you can learn more about what a person really wants through conversation.

Engaging in active listening helps you take in what the patient says—and what he doesn’t say. You’ll end up with with a more complete picture of his perspective and relevant experiences.

There are many methodologies that use active listening techniques. Some are used regularly in health care environments.

As just one example, the South East Local Health Integration Network (LHIN) suggests using Teach-Back. Teach-Back encourages the use of plain language and open-ended questions. During patient goal setting, this communication style can help care coordinators go beneath the surface to find out what’s really most important to patients.

Active listening is also about ensuring that patients understand. Practicing these skills—by, for example, having patients repeat what you’ve said in different words—can make challenging situations easier.

What happens when a patient is adamant about setting unrealistic health goals?

During a difficult conversation (in an already hectic day), it can be tempting to let the patient gloss over reality. Practitioners aren’t always aware that they’re doing it. Using methods like Teach-Back forces coordinators to notice discrepancies in understanding—and work towards achievable goals.

Improve Health Literacy

The Ontario College of Physicians and Surgeons estimates that low health literacy costs the health care system as much as $10 billion a year. Needless to say, there are also sizeable personal costs for patients who don’t fully understand their care.

During patient goal setting, care coordinators need to ensure they’re speaking the same language as those they’re helping. Without a patient’s full understanding, the chances that her wishes and preferences will be reflected in her care plan are slim to nil.

In health care, it’s inevitable. There are times when it seems like practitioners in different areas of specialization speak completely different languages. Unfortunately, the patient usually doesn’t speak any of them. As a care coordinator, part of your job is translation.

To a large extent, you’re also an educator. You can improve a patient’s health literacy by providing her with access to resources. Whether it’s a sheet of nutrition tips or a short video depicting a simple wound dressing technique, educational resources can improve understanding.

Fully understanding these processes and their outcomes allows patients to see a broader spectrum of goals. Suddenly, achieving feasible, short-term goals begin to make sense.

As much as possible, be available to answer questions—and ensure that other circle of care members are, too. Communication technology can help in this regard. Introducing intuitive and convenient digital communication systems can improve conversations between patients and their care teams.

By now, you’ve almost developed the sense that patients don’t always understand their care as fully as they think they do. Because patient-centredness is a relatively new concept, the onus is often on care coordinators to improve patient comprehension.

It’s wise to devote much of your effort to improving health literacy. Realistic goals that truly reflect patient wishes frequently follow.

Improve Patient Engagement

There’s no doubt in the minds of health care professionals. Patient engagement is critical. It has the power to improve health outcomes and quality of life. It increases the likelihood that care delivery will run smoothly. And when it comes to goal setting, engagement plays an important (and direct) role.

When a patient doesn’t understand the reasons for key care decisions, how can she be invested in their outcomes? When she doesn’t comprehend what’s happening well enough to track her progress, how can she be expected to set specific, realistic objectives?

Vague, big picture goals—such as “getting well”—are made in part because patients have trouble participating in the process. It’s up to care coordinators to ensure that patients are active participants in their care.

Of course, asking for involvement is no small request. It requires a patient’s energy—and in many cases, a major mental shift.

Past experiences with the health care system have led many to believe that they should be passive recipients of care. But Ontario’s system is shifting. Leaders have begun to recognize that a reactive, acute care approach to dealing with chronic disease isn’t always best.

The best way to engage a patient in her care is to help her understand how her actions can contribute to positive outcomes. If she knows she can make real strides toward her goals, she’s far more likely to want to participate in goal setting.

Celebrating progress is also key—it encourages patients to track their progress, take part in reevaluation, and adjust objectives accordingly.

When it comes to engaging at-home patients, communication apps can help. Intuitiveness is important, so look for features such as touch-screen accessibility.

Patient Goal Setting: Bring it All Together

As a care coordinator, you help patients set health goals that are both reasonable and satisfying. But during this process, there’s no shortage of potential challenges.

Luckily, focusing on communication can help. By ensuring patients understand all relevant health information and encouraging them to take an active role in their care, you can set them up for success.

Feature image by Markus Spiske

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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