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 healthcare 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 healthcare 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 healthcare 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 a difficult job. But it can also be very satisfying.

Active Listening

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 healthcare. Truly hearing a patient is about more than absorbing information. It’s about listening for specific information that will help you create a dialogue.

As much as possible, you want to align a patient’s goals with their 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 a complete picture of his perspective and relevant experiences. There are many methodologies that use active listening techniques. Some are used regularly in healthcare environments.

Remember the basics when engaging with patient goal-setting:

  • Eye contact
  • Pay attention to their body language
  • Ask open-ended questions about their goals
  • Listen and ask follow-up questions before providing feedback
  • Ask and plan how their goals will be achieved

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 healthcare 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 to 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 allow 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 circles 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 healthcare 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 healthcare 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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