Goal-Oriented Action and Learning for Multimorbidity Management in Primary Care (GOAL - MM)

GOAL-MM strengthens primary care systems by integrating Goal-Oriented Care (GOC) and digital multimorbidity management within an international Primary Care Practice-Based Research and Learning Network (PBRLN). The project advances practice-based research on digital services' impact on care continuity, patient engagement, and primary care efficiency while reducing institutional care dependence. The project deploys the Multimorbidity Management Health Information System (METHIS) platform across Portugal, Norway, and Canada, enabling real-time patient monitoring, predictive analytics, and personalized self-management tools to detect and manage multimorbidity decline. This platform supports both clinical care and research data collection while facilitating the development of a Learning Health System that promotes collaborative knowledge exchange, evidence-based decision-making, and best-practice standardization. Using a co-design and co-creation approach with healthcare professionals and patients, the project ensures sustainability through comprehensive economic and clinical evaluations examining cost-effectiveness, health system efficiencies, institutional care reduction, patients' health outcomes and satisfaction among patient and primary care providers. Through the engagement of key figures in WONCA and NAPCRG, the project contributes to the Global Practice-Based Research Network Initiative, a concept of a group endorsed by WONCA's Working Party on Research. It also serves as the inaugural multimorbidity priority for this initiative, developing a pilot data platform for WONCA's portal, with planned expansion to engage other PBRNs. Research outcomes will reach over 230 PBRN leaders and researchers through quarterly meetings, workshops, international conferences, and connections with affiliated groups facilitating the dissemination of scalable, evidence-informed multimorbidity management models across diverse healthcare systems.