Title: Goal-setting in care planning for people with multimorbidity: feasibility study and intervention refinement.
Funder: Department of Health and Social Care

Abstract: Personalised care planning is a conversation in which patients and clinicians agree goals and actions for managing the patient's conditions . Goal-setting, the sharing of realistic treatment goals by physicians and patients, is core to care planning, particularly for patients with multimorbidity. Goal-setting and action planning can improve physical and psychological health status and people s capability to self-manage their condition, compared to usual care. The problem being addressed is that usual care planning rarely involves goal-setting. Whilst developing this project, we reviewed the literature and held discussion groups with members of the public, GPs and geriatricians to identify potential barriers to goal-setting in primary care. We categorised barriers into Theoretical Domains Framework domains, including lack of knowledge and skills for goal-setting, doubt about capabilities, environmental (GPs can have difficulty meeting the needs of complex patients in a short consultation) and motivational and social influences on patients describing goals. We have designed the study to overcome these potential barriers. Patients with multimorbidity engage more in self-management if they have a sense of capacity, responsibility and motivation and hence may particularly benefit from a patient-centred, goal-setting intervention. The objectives of this feasibility study are to evaluate: the acceptability of goal-setting to patients and GPs; training needed by GPs; the content of care-planning consultations; recruitment, retention and response rates; selection of primary outcome measure; and identification of statistical parameters of the primary and key secondary outcome measures to help determine the sample size for the main study. The research plan is a cluster randomised controlled trial, to test the feasibility of goal setting as part of the care planning process in 60 patients with multimorbidity and at risk of unplanned hospital admission. The intervention has 2 stages: GP training in goal-setting as part of care planning, and then a GP care planning consultation which will use goal-setting. Assessing the achievement of diverse goals is important and we will use Goal Attainment Scaling, which gives a single outcome for the achievement of multiple goals, has an increased responsiveness to change in geriatric assessment, and is amenable to goal-setting in a person-centred manner. The control group will receive the usual care planning process. The training and intervention will be qualitatively evaluated using video and audio-recording of consultations, transcribed for in-depth analysis. Two focus groups of GPs and patients will use vignettes to assess acceptability of the goal-setting intervention. The quantitative and qualitative data will be triangulated and discussed with patients and GPs at a workshop to refine the intervention if required, and estimate the key parameters for a subsequent definitive randomised controlled trial of goal-setting within care planning consultations. NHS England is committed to care-planning for long-term conditions and proactive, personalised care has been promised for those with the most complex needs, for example through its Avoiding Unplanned Admissions Enhanced Service (ES) for primary care. Goal-setting is key to effective care planning, but is not specified in current care planning templates and payment schemes, such as the NHS ES. By introducing a goal-setting intervention and assessment to care planning consultations, this study has the potential to improve care planning across all patients, in addition to the 2% of patients at highest risk of unplanned hospital admission in 90% of all English practices taking part in the ES. We anticipate that this will translate into better self-management and improved measures of physical and psychological health in this group of patients, which may lead to fewer unplanned admissions and adverse effects, as well as less use of primary health care and lower costs.

Lay abstract: A care plan is an agreement between a patient and doctor that helps them both to look after the patient s health from day to day. A good care plan is owned by the patient and includes goals that are important to the patient and that they want to work towards, such as getting out of the house more, or taking fewer medicines. Over the past 2 years, nearly all general practices have offered care planning to patients at high risk of an unexpected hospital stay. Usual care planning may involve very little or no talking about patients goals, even though previous research has found that goal-setting can improve health. We plan to compare two groups of patients, those who have usual care planning, and those who have care planning with goal-setting. We will use an existing simple approach to setting goals and seeing how well goals are met, called Goal Attainment Scaling. We will use a short version that we think will work well in general practice, which has been used with patients but not yet tested in primary care. Before we can find out if goal-setting improves health in a full scale trial, we need to collect information in this research study. The information we will collect includes whether patients and general practitioners (GPs) like using goal-setting, whether GPs need training, whether we can collect the information we need about patients health, and the likely effect of goal-setting compared to usual care planning. We will run a small version of the planned future trial, called a feasibility study, with 3 general practices in the usual care planning and another 3 in the care planning plus goal-setting arm of the study, with about 60 patients. This research will help patients and GPs work together to better meet patients needs.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE