MAKE IT SMART - ELICITING AND ALIGNING GOALS IN HOME-BASED PRIMARY CARE

Sep 28, 2026

Home-Based Primary Care teams provide services to homebound older adults facing complex medical and psychosocial challenges. To prevent patients and providers from becoming overwhelmed by multiple concurrent issues, the project emphasized identifying meaningful, personalized outcomes and strengthening goal-setting practices. Within VA’s Whole Health model, a multi-step quality improvement initiative implemented team goals first, then elicited patients’ own SMART goals. Goal achievement was tracked every 90 days over two years, improving team goal attainment from 73% to 88% and sustaining 75% patient SMART goal achievement through motivational-interviewing coaching.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Background and challenge

SMART goal-setting in home-based care

Quality improvement implementation

Team goals followed by patient SMART goals

Tracking outcomes every 90 days

Results and team feedback

Innovation in Aging, 2025, Vol. 9, No. S2 17 Abstract citation ID: igaf122.055 MAKE IT SMART: ELICITING AND ALIGNING GOALS IN HOME-BASED PRIMARY CARE Pietra Bruni1, Tara McBride Afonso1, Brian Green1, Todd Paul2, Cynthia Knight2, Cherrylyn Alejo1, Laura Moore1, and Michelle Mlinac3, 1. VA Boston Health Care System, Boston, Massachusetts, United States, 2. Jamaica Plain VA Medical Center, Jamaica Plain, Massachusetts, United States, 3. VA Boston Healthcare System, Boston, Massachusetts, United States Home-Based Primary Care teams aim to deliver healthcare services to homebound older adults with complex medical and psychosocial issues. Both patients and providers can become overwhelmed with attempting to manage multiple issues simultaneously. Therefore, identifying outcomes that are meaningful to patients can be facilitated through identification of personalized goals. Utilizing a problem-solving approach was identified as a high competency of the interdisciplinary team. However, problem-solving can contribute to maintenance of the status quo in patient-provider interactions and to loss of enthusiasm for goal setting. As part ofVA’s Whole Health model, a multi-stepped quality improvement project was implemented within a home-based primary care team. First, the team implemented team goals for each patient and then once this had become routine process, they elicited patient’s own SMART goals. Achievement of these goals was tracked during care planning meetings, and friendly competition between teamlets to set and meet these goals helped to drive enthusiasm and buy-in. Measurement of meeting both team and patient SMART goals was tracked every 90-days across two years, resulting in the team’s ability to meet their own goals rising from 73% to 88% respectively. Obtaining patient SMART goals was built on training and coaching in motivational interviewing skills, and led to 75% of these patient goals to be met over time. Improvements in SMART goals were identified, with qualitative feedback from the team indicating an appreciation for the visibility of progress, modeling by other team members, and feeling a better connection in clinical work.

FAQs

Why did the project focus on SMART goals for home-based primary care patients?

The program targeted the challenge of patients and providers feeling overwhelmed when managing multiple issues, by identifying meaningful, personalized outcomes through goal-setting.

How was SMART goal-setting introduced in the quality improvement project?

The team first implemented team goals for each patient as a routine process, then elicited patients’ own SMART goals after that foundation was in place.

What training supported obtaining patients’ SMART goals and what impact did it have?

Patients’ SMART goals were supported with training and coaching in motivational interviewing skills, leading to 75% of patient goals being met over time.

Sep 28, 2026

Uploaded by Alex Sinclair