Table 1 Model case of Joseph to demonstrate GOC at the individual level

Joseph, 68 years old, suffers from diabetes, hypertension, and chronic obstructive pulmonary disease. Throughout his entire working life, he was a secondary school teacher. He has been retired for 3 years now (patients’ context). Despite the fact that he is limited by his health condition, he loves spending time gardening and playing with his grandchildren (patients’ needs and preferences).

A few years ago, he was a passionate cyclist, but his racing bike has been stored for a long time now. His friends encourage him to cycle with them on a weekly basis (patients’ context). His wife supports this initiative and argues that this will be beneficial for his social contact (patients’ context). Every month, Joseph visits his family doctor for a check-up. For each consultation, he prepares a list of things he wants to discuss. He has the chance to share his story in an open communication in which trust and mutual respect are key components (goal elicitation).

In his monthly check-up with his family doctor, he suggests his wishes to cycle again with his friends (patients’ needs and preferences & goal setting; interaction). His doctor doubts whether this will be possible, and after discussion and negotiation (goal setting; interaction), they plan that he would join his friends in their weekly cycling trip but only for the first 2 h (goal setting; foundation for SMART goal). The group will be asked to adapt their pace, and Joseph will make sure that he does not need to return back home on his own. The doctor makes adjustments to the medication scheme according to the increased efforts Joseph will make (goal setting; care plan). He will also contact the cardiologist to inform him about the changes to the medication schema (goal setting; care plan). The family doctor and the cardiologist will collaborate in order to succeed in Joseph’s goal (goal setting; care delivery). The family doctor and Joseph agree to discuss and evaluate the course after 3 months (goal evaluation; feedback & evaluation). It is possible to increase or decrease the intensity depending on Joseph’s health state and his own preferences (goal evaluation; evaluation).