Multimorbidity and ageing in the digital age: development of a multidisciplinary intervention based on Goal-oriented Care, Design Science and evidence to improve doctor-nurse-patient communication and information management

Dealing with patients with multimorbidity requires different tools. In 2016, 41% of patients with chronic diseases in Portugal had multimorbidity, with around 20% of patients having 4 or more chronic diseases. The Goal-oriented Care (GOC) approach is an alternative approach that focuses on the patient's goals. It consists of achieving maximum individual health potential through individually defined goals, based on what really matters to patients.

The research methodology is the Design Science Research Methodology, which helps to contextualize a solution to the problem under study, allowing objectives to be defined and results to be evaluated.

The results expected by health professionals are to obtain better performance through the construction of an information system that, based on GOC, allows for better management of chronic patients, bringing them closer to their doctor and their clinical team. It is also hoped that the patient will recognize and work on their goals for improvement, as agreed with the doctor, improving their adherence to therapy.