Operationalizing the Chronic Care Model with Goal-Oriented Care - PMC

Operationalizing the Chronic Care Model with Goal-Oriented Care - PMC

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. 

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By integrating a person’s life goals into the established Chronic Care Model framework, care becomes more meaningful — shifting from disease-targets to what truly matters for the individual.


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