Setting goals in chronic care: Shared decision making as self-management support by the family physician

Figures & data

Table 1. The three types of self-management (16) with a case example.

Type of self-management	Case example of a 65-year old woman with COPD
Medical self-management: Coping with symptoms and complying with treatment measures.	Learning to recognize an exacerbation and adjusting medication accordingly.
Social (role) management: Adjusting one's behaviour in order to maintain or adjust one's life roles.	Finding other ways to fulfil her role as grandmother.
Emotional self-management: Dealing with emotional reactions to a chronic condition, such as fear and depression, and coping with discomfort and disability.	Learning to deal with the fear of deterioration and the sadness that she is not able anymore to go to the playground with her grandchildren.

Table 2. The ‘5-A model’ of behaviour change (17) with case example.

The ‘5-A model’ steps	Case example of a 65-year old woman with COPD
Assess: Determination of medical and motivational conditions and the patient's current involvement in self-management, own wishes and needs, willingness to change, as well as current and desired level of knowledge.	The patient usually has exacerbations in autumn. She rarely visits a physician, but she wants to improve her condition in order to be able to visit the playground with her grandchildren. She is prepared to exercise to improve her condition and is willing to learn if there are groups of COPD patients she can join for sporting. She tells the physician that she finds it hard to cope with limitations, like not being able to care for her grandchildren.
Advise: Patient education and communication of specific information about health risks and the benefits of particular changes.	The physician informs her about the value of daily movement for improving condition and about weight management in relation to COPD.
Agree: Collaborative goal setting and action planning based on the patient's level of interest and confidence in their ability to change.	The patient and the physician agree on the patient's goals to improve her condition and to learn how to arrange sufficient movement in daily life in order to be able to visit the playground with her grandchildren again. They agree on a referral to a physical therapist.
	Furthermore, the patient sets a goal to learn to deal with the consequences of the disease. The physician and the patient discuss several options to reach that goal (e.g. patient support groups, referral to a psychologist). The patient decides to postpone the decision over possible actions. She also decides not to focus on weight management in this period.
Assist: Detecting and addressing any barriers that may interfere with the patient's achievement of his or her goals and supporting the patient in working on his or her goals.	The patient experiences difficulties in finding a physical therapist who offers group sport activities for patients with COPD. The physician informs her about a website where she can find sport groups for patients with COPD.
Arrange: Monitoring the patient in follow-up meetings which are scheduled in a clear and timely manner.	The physician and the patient agree to schedule a new appointment after finishing physical therapy to evaluate her condition and to review if any actions for reaching the goal to learn to cope with the disease are wished-for. The physician intends to ask how she feels about weight management at that moment.

Table 3. The ‘goal setting and action planning practice framework’ (19).

• Goal negotiation: Discussion of specific problems and potential goals

• Goal setting: Consideration of goal attributes like specificity, difficulty and compatibility with the patient’s level of involvement

• Planning: Making action plans and coping plans for carrying out the goals

• Appraisal and feedback: Evaluation of action plan outcome and goal progress

Table 4. Case example ‘International classification of functioning’ (29).

ICF domains	Case example of a 65-year old woman with COPD
Function: Body functions or structures	Increase depth of respiration
	Increase muscle strength
Activity: Activities	Being able to walk to the kindergarten and back
	Being able to wash/dress and feed children
Participation: Role performance	Being able to fulfill role as a grandmother
Environment: Physical, social and attitudinal environment	Daughter take limitations due to COPD in consideration when asking for help in taking care of kids
Personal factors: Lifestyle, habits, coping skills, etc.	Acceptance of limitations
	Being able to say no to requests when necessary

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