Goal Setting In Occupational Therapy - PowerPoint Presentation

1. Goal SettingInOccupational TherapySarena JonesAllied Health Support Servicessarena@alliedhealthsupport.com

2. ObjectivesUnderstand what a goal actually is…Understand what goal setting in OT meansUnderstand the importance of goal setting for both the therapist and the clientUnderstand goal setting models & outcome measures- SMART- COPM- PSFS- GASExplore and practice goal setting within the NDIS framework

3. What is Goal Setting? ‘The object to which effort or ambition is directed; the destination of a journey’ (Oxford English Dictionary)TWO components of a ‘goal’ The end state The effort to get thereA goal is therefore a ‘future state’ and in the context of rehabilitation, will usually mean a CHANGE from the current state (or a maintenance of current state if the client is expected to deteriorate)A goal refers to the INTENDED outcome as a result of actions undertaken by the client, supports and/or health professionals involved

4. WhyDo WeNEED To DOGoalSetting?Goal setting is considered to improve client engagement in therapy and make rehabilitation more meaningful to individuals. Far better client outcomesFor our clientsFor us as Clinicians… It informs your clinical reasoningGives you a clear plan for meaningful intervention that is more likely to achieve higher outcomesIf done correctly, you have measures of your success!The inability of patients to participate fully in the goal-setting process largely determines the approach taken by therapists (Leach et al 2009)

5. SMART GoalsSMART goals are a relatively new idea. In 1981, George T. Doran, a consultant and former director of corporate planning for Washington Water Power Company, published a paper, “There’s a SMART Way to Write Management’s Goals and Objectives.” In the document, he introduces SMART goals as a tool to create criteria to help improve the chances of succeeding in accomplishing a goal. (Eby, 2009)What does S.M.A.R.T goals mean to you??

6. SMART goalsS Specific – (smart, strategic, significant, simple…)M Measurable – ( meaningful, motivational, manageable…)A Achievable – (attainable, assessable, acceptable, actionable..)R Relevant – (realistic, reasonable, rewarding, recorded, robust…)T Time-Limited – ( trackable, tangible, timely…)E Evaluate, exciting, ethical, engagingR Re-Do, recorded, reviewed, rewardable (Wade 2009)

7. SMART goals – HOW TO!S Specific- The who/what/when/where/how questionsM MeasurableWhat metrics are you using to determine success?Formalised outcome measure?A AchievableDoes it required learning new skills? New attitudes or understanding?Does it require medical improvements? R RelevantIs it highly valuable for the client or carer?Why are we setting this goal now?T Time-LimitedWhat’s the deadline? Is it realistic timing? Short term Vs longer term goals or sub-goals…

8. SMART Goal E.g’sThe client will…Exercise for 30 minutes at least four days per week for two months.Achieve 8 hours minimum of sleep every night for 10 days, trackable via her watch.Attend Church each Sunday for 8 out of the next 10 weeks.Walk at least 10,000 steps tracked on a pedometer at least five days per week. Confidently and independently manage my own anxiety during grocery shopping by using my strategies, 3 times this month in order to complete my weekly grocery shopping in one trip.Quick THINK – personal goal example – then try to change it into SMART format… Share with the group or write it down in your notes!

9. SMART Goal - TIPSAs you’re listening to their story, ask ‘is that something I could help you to achieve? Is that something you would like to be able to do again?’Why is that important to you?When was the last time you were doing that activity? Eg walking 30mins, or playing piano, or sleeping 8 hrs a nightCombination of short-term (success is good!) and more difficult or longer term goalsWhat’s annoying you the most?? If you had a magic wand what would you change if you could?

10. Goal Attainment ScaleThe GAS was first introduced in 1968 and was intended for use in the evaluation of mental health services (Kiresuk & Sherman, 1968) GAS is an individualized outcome measure involving goal selection and goal scaling that is standardized in order to calculate the extent in which the client’s goals are met. Free and easy to use, however may be time consuming initiallyUsed in DVA funding modelsHighly valued in the literature as an outcome measureRecommended for use with clinically trained staff not assistants or admin staff as it relies on clinician’s ability to predict the outcome.May be applied at an individual level but then the data may also be translated and used at an organizational level

11. Goal Attainment Scale (GAS) - ScalingScoring the Goal Attainment Scale (GAS). Collaborative goal-setting exercise as a means of tracking individual progress over time. Goals must be meaningful to the subject. Good goals are characterized by being specific, measurable, achievable, realistic, and time-bound. Progress is measured against equidistant benchmarks ranging from − 2 to + 2 (McCue et al, 2019)

12. GAS:How are the goals scaled?GAS focuses on those problems, issues or symptoms that the intervention is expected to change. Eg issues list1. Identify the issues that will be the focus of the treatment2. Translate the selected problems into at least 3 goals3. Choose a brief goal title & indicator for each goal4. Specify the expected level of outcome for each goalBriefly worded goal. The indicator is the behaviour, future state, skill or process that represents the goal and can be used to indicate ‘progress’ This is often the most difficult part of the GAS. Requires understanding of the usual treatment outcomes, resources of the client, time allocated for intervention and therapist’s skills. Best to add some ‘grace’ to the predictionEG Achieve 6-8 hours of sleep every night for 2 weeks instead of predicting 7 hours. These can be rated in terms of the relevance or importance to the client.

13. GAS:How are the goals scaled?5. Specify the ‘somewhat more’ & ‘somewhat less’ levels6. Specify the ‘much more’ & ‘much less’ levels Discuss and record the levels that are much more and much less favourable.Discuss and record the levels that are somewhat more or less favourable.-2 Unable to carry and mobilise / requires assistance-1 Independently able but reduced safety, uses other hand to stablilise or other compensatory strategies. . Or 6-8 weeks?0 Independently carry hot coffee with affected UL from kitchen to dining table in 4-6 weeks. 1 Independently and safely carry hot coffee – 2-4 weeks. 2 Independently, confidently and safely carry hot coffee – 1-2 weeks. Or 2 coffees? Or hot meals?

14. GAS Example… & Quick Think! 62 yo man Parkinson’s DiseaseIssues: poor balance, poor fine motor control, difficulty with attention/problem solving/memory2. Goals : Independently able to dress self, inc upper and lower body in a reasonable time for 10 days consecutively. Confidently hold a pen and sign name. 3. Dressing – indicator of progress is upper body or lower body and / or days of the week and / or whether prompts/cues required4. Expected outcome may be Physically indep but requires prompts/cues for 10 days. 5. Less levels: Somewhat Less – Independently able to dress UB and LB with prompts for 5 days or indep with prompts for UB only. Much Less – Physical assistance still required for either UB/LB 6. More levels: Somewhat More – Indep either UB or LB with no prompts. Much more – indep both UB and LB with no prompts required

15. GAS Example… Quick Think!Think of a current client. Think of one of their goals. How can you turn it into a SMART goal?What would be the expected outcome??What could be the ‘progress indicator’ for that goal? Eg time, confidence, assistance, errorsThink about the potential levels – above and below the expected outcome…

16. Patient Specific Functional Scale (PSFS)Developed by Stratford et al 1995 as a self-report outcome measure of function that could be used in patients with varying levels of independence The aim of PSFS is to provide clinicians with a valid, reliable, responsive and efficient outcome measure that would be easy to use and applicable to a large number of clinical presentations.Simple, quick and easy. Clients often benefit from a visual scale.Functional, goal-oriented and client-centredCan be used from individual client’s perspective, but also to collect data from organisation’s perspective

17. Patient Specific Functional Scale (PSFS)

18. PSFSPatients are asked to identify up to five important activities they are unable to perform or are having difficulty with as a result of their problem eg putting socks on, shopping.2.Patients are asked to rate (on an 11-point scale) the current level of difficulty associated with each activity.3.Following the intervention, patients are asked again to rate the activities previously identified (and are given the chance to nominate new problematic activities that might have arisen during that time).4."0" represents “unable to perform” and "10" represents “able to perform at prior level”5.Patients select a value that best describes their current level of ability on each activity assessed.PSFS Method For Use

19. PSFS Eg & Quick Think…62 yo man Parkinson’s DiseaseOccupational Issues (identified through Ax)Difficulty with feeding due to tremorDifficulty with tying shoelacesDifficulty with writingDifficulty using the computer for online banking PSFS Goal Setting Can use a spoon for my cereal without spilling milk at all Performance score 2/10 Increase speed of tying shoelaces so I can be independent Performance score 4/10 Sign my name with confidence, accept by the bank Performance score 5/10

20. Canadian Occupational Performance Measure The COPM is a client-centred outcome measure for individuals to identify and prioritise everyday issues that restrict their participation in everyday living. This measure focuses on occupational performance in all areas of life, including self-care, leisure and productivity. This outcome measure is used with persons of all ages.Measures change in both performance and satisfaction. High reliability, validity and individualisedCOPM is based on the Canadian Model of Occupational Performance (CMOP) and was first published 1991 by 6 Canadian OT’s led by Mary Law.Manual + 100 measures $55 (+shipping)https://www.thecopm.ca/

21. COPM

22. COPM1. Problem definition – can be used in conjunction with the initial Ax. Discussion with client regarding the daily occupations they are having difficulty with. They are noted in the relevant areas on the form.2. Rating importance – client is asked to rate the importance of eachoccupation to their life, on a scale of 1-10 (useful to have a visual aid)3. Select problems for scoring – client chooses up to 5 of the most important problems for them and clinician enters those and their rating score on the scoring sheet.4. Score both performance and satisfaction for each – client is then asked to score both of these on a similar scale of 1-10 and the clinician records the scores.5. Re-assessment post interventionEndorsed online COPM learning module - $30 for the yearCOPM Method For Use

23. COPM Eg & Quick Think…62 yo man Parkinson’s DiseasePersonal Care - Issues identified with shaving, feeding, shoelaces. Productivity – Issues identified with hanging the washing, using computer for family banking and writing. Leisure – Issues identified with walking his dog, gardening. 2. Rated importance of these issues, top 5 were - 1. Walk dog (10) 2. Feeding (10) 3. Shaving (7) 4. Computer (6) 5. Writing (5)3. Walk dog Performance 3 Satisfaction 1 Feeding Performance 6 Satisfaction 3 Shaving Performance 2 Satisfaction 6 Computer Performance 6 Satisfaction 5 Writing Performance 5 Satisfaction 8*** What do you focus on for your treatment?? Think about your clinical reasoning… ***

24. Goal Setting in the NDISExpectationsAnyone can have, and achieve, goals regardless of disability, capacity or situationHP’s focus on the client’s goals and continually review the client’s goalsCore Funding (supports) Vs Capacity Building Funding (therapy) Vs Capital Funding (equip/mods)ChallengesClient’s don’t always know what they want to work on or find it hard to understand that they can improve/progress in different waysTime pressuresSupport Coordinator/Family/Service Providers – differing expectations?!StrategiesClear goal settingClear transparent communication – verbal and writtenExpectation management from the startUnderstanding your scope and role as the OT and other stakeholders’ rolesUse of goal setting tools

25. Goal Setting in the NDISDomain - ACTIVITIES OF DAILY LIVING Client Goal - I want to be more independent with ADLsGoal Setting (!)Assistance from a support worker to attend to my personal care needs each morning/eveningAssistance from a support worker to help me to learn budgeting or how to organise my time and day I would like my home or car to be modified to enable me to live and drive independently I would like support to learn how to cook healthy meals I would like support to learn to travel on public transport independently Are these goals client centred? How will the client know if they are successful?Are these goals Subjective / Measurable / Applicable / Realistic / Timed?Are these goals going to help YOU clinically reason and plan your intervention?Are these goals going to help your client maximise independence?

26. Goal Setting in the NDISDomain - ACTIVITIES OF DAILY LIVING Client Goal - I want to be more independent with ADLsGoal Setting (!)Assistance from a support worker to attend to my personal care needs each morning/eveningAssistance from a support worker to help me to learn budgeting or how to organise my time and day I would like my home or car to be modified to enable me to live and drive independently I would like support to learn how to cook healthy meals I would like support to learn to travel on public transport independently REAL GOAL SETTING… Think SMARTIndependently able to dress self, inc upper and lower body in a reasonable time for 10 days consecutively. Independently able to manage daily medications using a dosete box without errors for 2 weeks.Reduce urinary incontinence episodes by 50% over the next 7 daysUse of a Goal Setting Outcome Measure?? GAS / COPM / PSFSIntervention Plan – Clinical ReasoningTask specific practice for dressing, ?strategies for cognition, ?exercises for fine motor coordination, liase with PTTask specific practice with a dosete, ?reminders, visual cues, SV for 7 days prior with prompts, then SV no promptsToileting routine, prompts/mobile phone reminders. Work on mobility.

27. Goal Setting in the NDISDomain - ACTIVITIES OF DAILY LIVING Client Goal - I want to be more independent with ADLsGoal Setting (!)Assistance from a support worker to attend to my personal care needs each morning/eveningAssistance from a support worker to help me to learn budgeting or how to organise my time and day I would like my home or car to be modified to enable me to live and drive independently I would like support to learn how to cook healthy meals I would like support to learn to travel on public transport independently REAL GOAL SETTING… Think SMARTUse of a Goal Setting Outcome Measure?? GAS / COPM / PSFSIntervention Plan – Clinical Reasoning

28. Goal Setting in the NDISDomain - ACTIVITIES OF DAILY LIVING Client Goal - I want to be more independentGoal Setting (!)Assistance from a support worker to attend to my personal care needs each morning/eveningAssistance from a support worker to help me to learn budgeting or how to organise my time and day I would like my home or car to be modified to enable me to live and drive independently I would like support to learn how to cook healthy meals I would like support to learn to travel on public transport independently REAL GOAL SETTING… Think SMARTUse of a Goal Setting Outcome Measure?? GAS / COPM / PSFSIntervention Plan – Clinical Reasoning

29. References & Further ReadingAshford S & Turner-Stokes, L. (2014). Chapter 7: Goal Attainment Scaling (GAS) in adult neurorehabilitation. Handbook of Rehabilitation Goals Setting. Taylor & Francis, UK. Cusick A, McIntyre S, Novak I, Lannin, N & Lowe, K. (2006) A comparison of goal attainment scaling and the Canadian occupational performance measure for paediatric rehabilitation research, Pediatric Rehabilitation, 9:2, 149-157, DOI: 10.1080/13638490500235581Debreceni-Nagy A; Horváth J; Nagy S; Bajusz-Leny A; Jenei, Z. (2019). Feasibility of six-point Goal Attainment Scale among subacute and chronic stroke patients. International Journal of Rehabilitation Research, 42 (4): 365-370. Eby, K. (2009). The Essential Guide To Writing SMART Goals. Smart Sheet Blog. https://www.smartsheet.com/blog/essential-guide-writing-smart-goalsGrant, M. & Jennie Ponsford, J. (2014) Goal Attainment Scaling in brain injury rehabilitation: Strengths, limitations and recommendations for future applications, Neuropsychological Rehabilitation, 24:5, 661-677, DOI: 10.1080/09602011.2014.901228Hefford C, Abbott JH, Arnold R, Baxter GD. (2012). The patient-specific functional scale: validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems. Journal Of Orthopaedic & Sports Physical Therapy. 42(2):56-65Kiresuk TJ, Sherman RE. (1968). Goal attainment scaling: a general method for evaluating comprehensive community mental health programs. Community Mental Health Journal. 4(6):443–53. https://doi.org/10.1007/BF01530764.Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H & Pollock N. (1990). The Canadian Occupational Performance Measure: An Outcome Measure For Occupational Therapy. Canadian Journal of Occupational Therapy, 57: (2) 82-87. Ogbeiwi, O. (2017). Why written objectives need to be really SMART, British Journal of Health Care Management 23(7):324-336

30. References & Further ReadingLeach E. Cornwell P, Fleming, J & Haines, T. (2010) Patient centered goal-setting in a subacute rehabilitation setting, Disability and Rehabilitation, 32:2, 159-172, DOI: 10.3109/09638280903036605McCue, M., Parikh, S.V., Mucha, L. et al. Adapting the Goal Attainment Approach for Major Depressive Disorder. Neurology Therapy 8, 167–176 (2019). https://doi.org/10.1007/s40120-019-00151-wNicholas P, Hefford C, Tumilty S. (2012). The use of the Patient-Specific Functional Scale to measure rehabilitative progress in a physiotherapy setting. Journal of Manual & Manipulative Therapy. 1;20(3):147-52.Saito, Y. Tomori, K. Nagayama, H. Sawadai, T. & Kikuchi, E. (2019). Differences in the occupational therapy goals of clients and therapists affect the outcomes of patients in subacute rehabilitation wards: a case-control study. Journal of Physical Therapy Science, 31 (7): 521-525. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642888/Stratford P, Gill C, Westaway M, & Binkley J. (1995). Assessing disability and change on individual patients: A report of a patient specific measure. Physiotherapy Canada, 47: 258-263. Wade, D T. (2009). Goal setting in rehabilitation: A overview of what, why and how. Clinical Rehabilitation; 23: 291–295 https://journals.sagepub.com/doi/pdf/10.1177/0269215509103551https://clik.dva.gov.au/rehabilitation-policy-library/15-goal-attainment-scaling/151-introduction-goal-attainment-scalinghttps://www.physio-pedia.com/Patient_Specific_Functional_Scale

31. Quick Reflection…What stood out to you today?What have you learnt today?What reasoning processes or models do you tend to use?What strategies do you tend to use now to support your reasoning?How will you incorporate your learnings today into your professional role?How will this impact on your clinical practice?Where / when will you record this and your reflection of this pd session??? Hint: do it now!

32. Questions?Sarena JonesOccupational TherapistClinical Supervisor & Consultantsarena@alliedhealthsupport.com