Goal-Driven Health -A New Approach to Helping People to Thrive

A new term may be helpful in the world of health and healthcare entrepreneurship in particular aimed at galvanizing individual health or motivating people’s health focus: "Goal-Driven Health".

 Just to define what we mean by this term here, Goal-Driven Health is based on achieving individualized health or wellness goals that are created through collaborative conversations between individuals (or what much of healthcare tends to unhelpfully call ‘patients’) and providers in health care settings. In this situation, the future health or perhaps better expressed ‘wellness’ goals are unique to the individual and then help to direct the future plan of action or steps towards better health or a state of ‘thriving’. This goal-driven approach is in contrast to a ‘problem-oriented’ or disease/condition-driven care, where the focus is on identifying health problems or challenges and planning to make care interventions when a projected or actual deviation from the so-called ‘norm’ is likely to occur.

A little History

Even though the ‘Goal Driven Health’ term may be relatively new, the general approach goes back to the family physician James Mold in the early 1990’s. Mold proposed that, before considering diagnostic and therapeutic strategies, clinicians and their patients should jointly agree upon their goals. He defined a goal as a desired outcome that is essential to the patient and proposed that four major goal types are relevant:

1) prevention of premature/preventable disability (and even death);

2) maximization of current health-related quality of life;

3) optimization of personal growth and development; and

4) improving the chances of a good life (and even a ‘good’ death -one with minimal pain and suffering after a long and healthy life, ideally).

As we can see from this approach, what is suggested here as ‘Goal-Driven health’ as Mold conceived it, is compatible with a wide variety of prevailing patient-focused strategies, including evidence-based medicine, patient-centered care, and shared decision-making. However, the focus of ‘Goal Driven Health’ here, is that the goal is formed prior to the development of any plan of care and most critically is based upon the individual’s resources and abilities, values and preferences and then goals and priorities. In other words, the person’s health conditions (such as they are and good or poor) are secondary to who the person is and therefore take most account of that individuals’ personality, life goals, knowledge and experience (and the advantages and disadvantages this may contribute) and last, but not least, his or her personal beliefs as a basis for the goals which are then evolved. In these circumstances, we need to be much more focused on the individual’s fundamental motivation to change and guide his or her future efforts, and how this might be influenced (or ‘nudged’) of which we will have more to say later.

Why is Goal Achievement so Difficult?

In matters of health and wellness, even when we do know quite a lot of background on who a person is in personality, lifestyle and values terms, it’s clear that most people may need assistance in goal-setting since many may not stay with even what appear to be personally desirable or relatively ‘easy’ objectives (such as to ‘get fit’, ‘lose weight’ or ‘relax more’). We see this every year with personal New Year resolutions which typically start to falter (sometimes within hours or days of being set!). While this confirms that setting goals for any kind of behavior change is difficult, there are ways in which we can craft the goals we set to improve the chances of future success. One major way to do this is to ensure that we evolve well-informed, personally tailored and attainable goals, with jointly establish milestones and benchmarks that better speak to each individual. In short, if the goal is properly constructed, and jointly crafted (and carefully ‘slotted’ into daily life), we increase the likelihood of resonating with each individual, regardless of where they are on their personal-health or wellness path or journey 

The Role of Individual or Patient Readiness or a Person’s Activation Potential

What may be argued to be an extension of Mold’s original work, Judith Hibbard, at the University of Oregon developed a Patient Activation Measure (PAM) that aimed to assess an individual’s or patient’s knowledge, skill, and confidence in managing their health and healthcare, as a baseline from which to spring and set improvement goals. The model describes 4 stages or levels of so-called ‘activation’ that people start with (and perhaps can be encouraged to change or improve in the process of becoming fully competent managers of their own health and healthcare and potentially able to progressively become capable of achieving improvement goals. Dr. Summer Knight in her book ‘Humanizing Healthcare’ calls this a person being able to ‘drive their body’ and its needs like they would their car-they are ultimately in charge and primarily responsible, including knowing when it needs the right equivalent of gas and maintenance! Hibbard’s 4 level system is shown in the chart below.

 Although this is clearly only one way in which to think about ‘readiness’ or ‘activation potential’ in an individual, it does allow us to then chart a simple risk profile. 

Since the introduction of the PAM, a number of studies have looked at the correlation between patient activation potential and better healthcare outcomes having set specific goals. Findings from such studies have shown that well-activated patients are more likely to experience better health outcomes compared with less-activated people (particularly when they are motivated to use digital health applications to help in the wellness or recovery from illness). These same studies also show that fully Activated patients also have a much better understanding of their disease/condition, which translates to better knowledge of how to manage their situation and the side effects of therapy (and are usually much more willing to use digital health tools to help). In other words, highly Activated individuals more readily recognize how factors such as excess weight, smoking, poor sleep sedentary/low exercise behavior, failure to manage personal stress and failing to manage chronic conditions, or drug adherence (for example) put them at increased risk.

The Benefit of Rigorous Assessment

While the simple PAM tool is just one classification system that can be used to assess an individual or patients’ readiness to self-manage and even adopt a digital health technology to help them, perhaps, an individual’s relative activation potential is a reasonably sound baseline to establish in any system that seeks to make goal-driven health successful, both in general and when electing to use digital health support tools to assist them (such as wearables, smart phone apps, desktop software or tablets or even other devices). Of course, many people are now more ‘connected’ to technology than ever before. This means that such people are now well-equipped to be activated and engaged when it comes to taking control of their healthcare (and to use these digital health applications to assist in doing so). This high level of connectivity and broad engagement is also a great opportunity for both existing healthcare system players or health-focused startups and entrepreneurs to put in place novel or innovative strategies to keep engaging an individual. This is not without its challengers, however, perhaps the greatest of which is the best mechanism by which to assess who a person is and what might then work best for them in goal terms that he or she is most likely to achieve.

In order to make effective behavioral change of any kind, one way in which we might gather useful data about an individual is to use a self-assessment to help determine a baseline or starting point. This should be short enough to make completion levels high but long and/or detailed enough to provide really useful feedback that is actionable. While many digital health or telemedicine apps (from healthcare organizations or startup companies in the health-focused field) require initial self-assessments on data such as age, gender, height and weight, for example, most do not offer an initial assessment or baseline metrics at a deeper and more useful level. Having these deeper metrics in place would help individuals track progress and make informed decisions based on their current state and future goals.

In addition to a self-assessment, a complimentary third-party ‘case assessment’ process is also useful to help understand the person in question and even compare it where applicable with their self-perception. However, the greatest value here to two-fold. Firstly, to ask ‘contextual’ questions about the individual which may have an influence on his or her health. Very often these are wider issues that have more of an ongoing influence than we might expect such as financial pressure (e.g. a lot of debt) or mobility issues (such as do they own and drive a car or rely on public transport?). One large category here is the so-called ‘social determinants or health’ which looks at a range of influences such as housing adequacy and location, relative education levels, quality of food consumed, availability of quiet open space and even social connectivity/loneliness issues, etc. Secondly, we can ask the ‘tell me more’ question that seeks to get underneath an issue or go deeper. An example here might be in a response to a ‘yes’ answer on the question such as ‘do you feel lonely often?’ the ‘tell me more’ question might elicit ‘my pet died recently and I’d like to get a new one soon’ (which might well be all the company or support the person needs).

In combination, these two assessments (self and third-party) can create a rich and powerful insights into a person and can then serve as a foundation for not only setting reasonable and attainable goals but ones that are more likely to be achieved with the right prompts or nudging to help

Helping an Individual effect Change for the Better -Nudging for success

Since Chicago Booth School academics Richard Thaler and Cass Sunstein’s book ‘Nudge’ emerged in 2009 they have been many others (including the deep research by Daniel Kahneman) the whole field of ‘nudge theory’ or now better known as ‘behavioral economics’ has made significant inroads in many sectors and in business, in particular. Although it can be argued that health and healthcare has been slow to adopt this approach of motivating and prompting people to change their current habits to get to healthier outcomes, it has been used in many settings and its future potential in this space is huge.

As it applies to the health realm, behavioral economics, at the most fundamental level, is about influencing people to select options that lead to a better outcome for themselves and increase their capacity to thrive in the short, medium and longer-term. This is often called ‘choice architecture’ and may be as simple as inviting someone to make the effort to ‘opt out’ rather than ‘opt-in’ (relying on the fact that opting to do anything new takes time and effort than many people will not easily expend). The example often quoted here is organ donation, where ‘opt-in’ effort means donation rates can be very low (less than 20% in the US) and quite high in countries where the ‘opt-out’ system has been introduced (sometimes as high as 80% of people not making the effort to ‘opt-out’. This choice architecture may also be quite sophisticated however, and even ‘gamify’ or indirectly or directly ‘reward’ an individual for the ‘right’ behavior or habit choices, especially when he or she sticks to them. An example here might be nudging people to adopt a lower fat/less sugar-oriented diet and then both including their efforts in a weight loss ‘competition’ and even paying them to achieve certain reduction targets.

In broad terms, behavioral economics stresses the importance of establishing meaningful base reference points, because people use them to measure progress and assess value—that is, people use these reference points as anchors for future decision making. Examples of anchored reference points might be the appropriate amount of steps to strive for each day as a minimum which act as a simple and prevailing daily goal to ‘fit-in’ by walking a short distance rather than driving a car, for instance. Naturally, for any desired activity or pursuit or habit change, when these reference points deviate too far from expectations or seem too difficult to attain, people tend to quickly lose interest. The ‘trick’ therefore is to use both the self and case assessment to appreciate what amounts to a sound target that represents a small change for the better but not so great as to create too much inertia and a lack of action. The psychologist and author BJ Fogg calls this a ‘Tiny Habit’ and argues that starting small and celebrating little ‘wins’ is motivating and allows other tiny habit changes to be added progressively. In the longer-term, this leads to relatively significant change and goal-directed health when applied in this manner becomes a success. In other words, we incent each person to enact change which gets them from level 1 in the PAM model we described earlier all the way to level 4 -A much better place for them to be!

So, in summary, then, readiness for activation or engagement is extremely important but Goal driven Health as it is suggested here would have the following steps:

1.    Use a well-structured self-assessment to appreciate the individual’s broad preferences, lifestyle, values and attitudes, as well as, what matters to them most, especially as it relates to his/her health

2.    Use a well-structured case assessment process to corroborate the above and add to it but also explore how the person actually lives his/her daily/weekly life and how he/she might ‘slot in’ changed and ‘healthier’ behaviors.

3.    Jointly set small or ‘tiny’ habit-change goals to improve health with the person, for which they are not only motivated mentally but are designed to have the least difficulty or friction possible.

4.    Jointly Design the prompting or nudging system likely to work best for the individual.

5.    Jointly Design the recognition or reward system likely to work best for the person.

6.    Set new small/tiny goals that build on earlier ones jointly to shift healthy habits even further

7.    Collect regular feedback, adjust and add in as many health areas as needed to thrive.

Jon Warner is CEO of Silver Moonshots-www.SilverMoonshots.org, a research and support organization for enterprises interested in the 50+ older adult markets with its own aging-focused virtual accelerator. He is also Chapter Ambassador for Aging 2.0 and on the Board of St Barnabas Senior Services (SBSS), in Los Angeles, California.