1) Clarify important activities and relationships

2) Explore underlying values

3) Identify obstacles, challenges, and opportunities

1) Train office staff in the goal-oriented approach

2) Provide patient information about goal-oriented care

3) Develop protocols that facilitate pre-visit information collection, access to outside records, medication, and family involvement when desired

4) Create electronic record templates to facilitate goal-oriented data collection and documentation

1) Share relevant information

2) Brainstorm strategic options

3) Negotiate an initial plan

1) Develop strong professional relationships with rehabilitation therapists, home health agencies, and community resources.

2) Create paper or computer order set templates that include goal-focused referrals to rehabilitation therapists, home health clinicians, durable medical equipment, and community resources

3) Develop a process that engages non-physician clinicians and office staff in care plan construction and communication.

4) Create a referral letter template that specifies patient goals

1) Establish an implementation support plan

2) Adjust the plan based upon new information

1) Create a care plan template that includes follow-up arrangements, contact information, and contingency plans that can be easily incorporated into visit summary and referral letters.

2) Develop a process that engages non-physician clinicians and office staff in care plan implementation and oversight.

3) Create a documentation process that makes it possible to track progress and adjust goal-oriented plans of care.