I have served as a goals facilitator at the Patient Priorities Care pilot program at ProHealth Physicians since September of 2016. In this role, I make home visits to patients aged 65 and older in order to determine their personal health and life goals. I initiate the conversation with patients by obtaining their most significant life values. If the patient is more focused on what is not working with their health care, we shift the conversation by inquiring what the patient would be doing more of if their complaint or ailment were not as burdensome. I then coordinate with the patient’s team of doctors to streamline their care, based upon the patient’s priorities.

I once worked with a patient – I’ll call her “Susan” – who felt burdened by having to use her CPAP machine each night. She said she thought it was increasing her restless leg syndrome and noted increased pain in her legs and feet.

When Susan and I discussed her health goals, she mentioned a monthly meeting that she had been a part of for 40 years. She said she wanted to be able to stand and greet friends at the meeting with less pain in her legs and feet.

When we reviewed her medications together, Susan admitted that she was not consistently administering her Ropinirole – which was intended to control her restless leg syndrome. I relayed this to her primary care provider and she instructed me to have the patient come in for an office visit to discuss altering her care based on her current life outcome goals and care preferences.

By sharing Susan’s goals with her primary care provider, we opened the door for her to have a dialogue with her doctor about what she was able and willing to do to achieve optimum health. The doctor decided to communicate the inconsistent use of the CPAP machine, with her cardiologist, order physical therapy and wound care, and implement gait training and lymphedema care. So far, Susan has noted that she’s feeling better, no longer has to use her CPAP machine and is walking greater distances with minimal discomfort.

I think this approach to healthcare gets to the core of what matters most to patients: what do they want to achieve for their own health and what will they do to get there? I’m proud to play a role in the process as a goals facilitator, helping clinicians and patients start a larger conversation that can allow patients to feel more satisfied with their care, reduce their burden, and help them achieve the life outcomes they really want.