Keywords: Multimorbidity, PBRN, Goal-Oriented Care

Background:

Multimorbidity is increasingly prevalent in ageing populations and poses major challenges to primary care systems traditionally organised around single disease-specific models. Goal- Oriented Care (GOC) has been proposed as a person-centred approach that prioritises what matters most to patients, yet evidence on its real-world effectiveness, cost-effectiveness, and scalable implementation remains limited. This pilot project is endorsed by the Global Practice-Based Research Network (PBRN) Initiative, aligning with its key research areas.

Research questions:

To evaluate the effectiveness, cost-effectiveness, and sustainability of a digitally supported GOC approach (METHIS) for adults with multimorbidity, supported by Learning Health System (LHS) principles embedded within participating PBRNs.

Method:

This multinational study will use a stepped-wedge cluster randomised controlled trial involving patients aged 60+ with multimorbidity in primary care practices within PBRNs in Portugal, Canada, and Norway. The intervention, introduced sequentially in each practice, comprises: (1) structured GOC training for primary care teams; (2) implementation of the METHIS digital platform to support goal elicitation, shared decision-making, and monitoring; and (3) application of LHS principles, including patient engagement to promote continuous learning and improvement.

Results:

The study will generate longitudinal data on health-related quality of life, healthcare utilisation, and implementation outcomes across participating practices. EQ-5D-5L changes from baseline will be assessed at 6-month intervals up to 24 months across intervention and usual care periods,
alongside the incremental cost-effectiveness ratio (ICER) and quality-adjusted life years (QALYs). Secondary results will include patient-reported mental health, functional ability, care experience, professional experience, healthcare utilisation, and resource use. Adoption, fidelity of GOC, and digital engagement with the METHIS platform will inform assessment of implementation and sustainability.

Conclusions:

This study aims to generate robust, practice-based evidence on digitally reported GOC for people with multimorbidity, supported by LHS, and to inform future embedding and scaling of this person-centred model within diverse primary care systems.

Points for discussion:

To what extent can digitally supported, goal-oriented care improve patient-relevant outcomes for people with multimorbidity when implemented at scale in routine primary care and supported by Learning Health System (LHS) principles?

What are the implications of combining digital Goal-Oriented Care and LHS approaches for equity, particularly for older adults and for patients with lower health, digital, or social literacy? Which components of the intervention (training, digital tools, LHS processes) appear transferable across different primary care systems and countries, and what adaptations are required to ensure local relevance and feasibility?

What can be learned from the application of LHS principles regarding continuous learning, feedback loops, and patient engagement in the implementation of Goal-Oriented Care in primary care? Which organisational, professional, and contextual factors influence the adoption, fidelity, and long-term sustainability of digitally supported Goal-Oriented Care within primary care practices and PBRNs?