Goal planning in person-centred care supports older adults receiving case management to attain their health-related goals

Figures & data

Figure 1. Overview of the goal-planning process within Embrace, with two goal plan examples. GeriatrICS = Geriatric ICF Core Set, or not to the editor’s taste. Baseline score: The severity of a problem identified during the assessment. Target score: The score the older adult intended to attain by performing the planned activities to address the specific problem. End score: The severity of the health-related problem after at evaluation. Baseline score, target score, and end score are severity scores and range from 0 to 10 with higher scores indicating more severity. Feasibility score: The likeliness of a goal to be attained was rated to make older adult expectations explicit, discussed and adjusted accordingly. Score ranges from 0 (totally unlikely) to 10 (certainly feasible). Black: older adult in charge; Grey: older adult and the case manager mutually in charge; light grey: initiated by the case manager. In italic: example of care and goal plan.

Figure 2. Flowchart of inclusion of eligible older adults (n), separated for the complex care needs and frail risk profiles, and their goal plans (k). *Proportion of older adults (and goal plans) included in analysis of the sample eligible for goal plan development. NH: nursing home; n: number of older adults; k: number of goal plans; within grey box: older adults from control group and robust care profile: they did not receive individual support from a case manager and therefore formulated no goals plan.

Table 1. Baseline characteristics for the total older adult sample and for each risk profile.

	Total	Complex care needs	Frail
	n = 233	n = 133	n = 100
Age, mean (SD)	81.5 (4.7)	81.5 (4.6)	81.5 (4.8)
Male gender	75 (32)	41 (31)	34 (34)
Married	115 (49)	70 (53)	45 (45)
Living situation
Community-living with others	119 (51)	71 (53)	48 (48)
Community-living single	109 (47)	58 (44)	51 (51)
Residential care	4 (2)	4 (3)	1 (1)
Educational level
(Less than) primary school or low vocational training	127 (54)	72 (54)	55 (55)
Secondary professional education	85 (37)	52 (39)	33 (33)
Higher professional education/university	20 (9)	8 (7)	12 (12)
Using more than three medications	182 (78)	111 (84)	71 (71)
Number of chronic conditions, median (IQR)	3 (2–4)	4 (2–5)	3 (1–4)
Frailty^a, median (IQR)	6 (5–8)	7 (5–8)	6 (5–7)
Care complexity^b, median (IQR)	16 (12–20)	19 (17–22)	12 (10–14)
(I)ADL constraints^c, median (IQR)	3 (1–5)	4 (2–6)	1 (0–3)
Health status^d, mean (SD)	0.68 (0.17)		0.76 (0.12)

Data are expressed as numbers (percentage) unless stated otherwise.

IQR: Inter Quartile Range; ADL: Activities of Daily Living.

^a GFI = Groningen Frailty Indicator (range 0–15), a higher score indicates more frail.

^b INTERMED SA – E = INTERMED for the Elderly Self-Assessment (range 0–60), a higher score indicates more case complexity.

^c Modified KATZ ADL/IADL (range 0–15), a higher score indicates more (I)ADL constraints.

^d EQ-5D (range 0–1), a higher score indicates a better health-related quality of life.

Figure 3. Prevalence of goal plans (n = 836) among older adults (n = 233) and for each risk profile, categorized into six predefined clusters and three other highly prevalent ICF-categories. Dark grey: total sample; black: complex care needs; light grey: frail.

Table 2. Goal-planning results.

	Goal plans,	Baseline score,	Target score,	End score,	Δ End – baseline score	Δ End – target score	Goal attainment
	n =	mean (SD)	mean (SD)	mean (SD)	mean (SD)^a	mean (SD)^a	% (CI)
Overall sample	836	6.0 (2.0)	3.3 (2.0)	3.5 (2.4)	−2.5 (2.3)	0.2 (1.9)	74 (71–77)
Risk profile:
Complex care needs	519	6.0 (1.9)	3.1 (2.0)	3.4 (2.3)	−2.5 (2.6)	0.3 (1.7)	74 (70–78)
Frail	317	6.1 (2.2)	3.7 (2.1)	3.6 (2.4)	−2.6 (2.1)	−0.1 (2.1)	74 (69–79)
p Value for difference between risk profiles		0.25	<0.001	0.19	0.37	0.016	0.96
GeriatrICS clusters
Mental health	110	6.1 (1.9)	4.0 (1.9)	4.1 (2.3)	−2.1 (2.3)	0.1 (1.9)	75 (66–82)
Physical health	233	5.9 (1.9)	3.2 (2.0)	3.1 (2.3)	−2.8 (2.2)	−0.1 (1.8)	78 (72–83)
Mobility	176	6.1 (1.9)	3.7 (1.9)	3.9 (2.4)	−2.3 (2.2)	0.2 (2.0)	69 (62–76)
Personal care	8	6.1 (1.6)	2.5 (1.8)	2.4 (1.7)	−3.8 (2.8)	−0.1 (1.1)	88 (53–98)
Nutrition	42	5.3 (2.1)	2.9 (1.8)	3.1 (2.1)	−2.2 (2.1)	0.1 (2.2)	74 (59–85)
Support	165	5.9 (2.3)	2.7 (2.2)	3.0 (2.4)	−2.9 (2.5)	0.4 (1.9)	75 (67–81)
Other ICF-categories
Pain	68	6.7 (1.7)	3.9 (1.9)	4.3 (2.2)	−2.3 (2.0)	0.4 (2.0)	68 (56–78)
Looking after one’s health	17	6.0 (2.6)	2.4 (2.2)	2.9 (2.5)	−3.1 (2.8)	0.6 (1.3)	76 (53–90)
Recreation and leisure	17	4.8 (2.2)	2.2 (2.0)	2.2 (2.0)	−2.5 (2.4)	0.0 (0.9)	76 (53–90)

Scores are rated by the older adult and can range from 0 to 10 with higher scores indicating more severity.

Δ End – baseline score (goal progress): a difference below zero represents goal progress.

Δ End – target score: a difference below zero represents a goal more improved than aimed for.

Goal attainment: the prevalence of goals with a Δ End – target score ≤0.

^a Difference between the result for the ‘Δ-columns’ and extracting the respective scores is due to rounding off the results to the first decimal.

Data availability statement

Dataset is available upon request from corresponding author.