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

Eur J Gen Pract. 2015 Jun;21(2):138-44. doi: 10.3109/13814788.2014.973844. Epub 2014 Dec 26.


Introduction: Self-management is considered a potential answer to the increasing demand for family medicine by people suffering from a chronic condition or multi-morbidity. A key element of self-management is goal setting. Goal setting is often defined as a moment of agreement between a professional and a patient. In the self-management literature, however, goal setting is regarded as a circular process. Still, it is unclear how professionals working in family medicine can put it into practice. This background paper aims to contribute to the understanding of goal setting within self-management and to identify elements that need further development for practical use. Debate: Four questions for debate emerge in this article: (1) What are self-management goals? (2) What is necessary to accomplish the process of goal setting within self-management? (3) How can professionals decide on the degree of support needed for goal setting within self-management? (4) How can patients set their goals and how can they be supported?

Implications: Self-management goals can be set for different (life) domains. Using a holistic framework will help in creating an overview of patients' goals that do not merely focus on medical issues. It is a challenge for professionals to coach their patients to think about and set their goals themselves. More insight in patients' willingness and ability to set self-management goals is desirable. Moreover, as goal setting is a circular process, professionals need to be supported to go through this process with their patients.

Keywords: action planning; chronic disease; goal setting; goals; multi-morbidity; primary health care; self-care; self-management; shared decision making.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Chronic Disease / therapy*
  • Decision Making*
  • Family Practice*
  • Goals*
  • Humans
  • Self Care*