Goal Setting
In
Occupationa
l Therapy
Sarena Jones
Allied Health Support Services
sarena@alliedhealthsupport.com
Objectives
Understand what a goal actually is…
Understand what goal setting in OT means
Understand the importance of goal setting for both the therapist
and the client
Understand goal setting models & outcome measures
- SMART
- COPM
- PSFS
- GAS
Explore and practice goal setting within the NDIS framework
‘The object to which effort or ambition is directed; the destination of a
journey’ (Oxford English Dictionary)
TWO components of a ‘goal’
What is
Goal
Setting?
1.The end state
2.The effort to get there
A 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
For our clients
Why
Do We
NEED
To DO
Goal
Setting?
Goal setting is considered to improve client engagement in
therapy and make rehabilitation more meaningful to
individuals.
Far better client outcomes
For us as Clinicians…
It informs your clinical reasoning
Gives you a clear plan for meaningful intervention that is
more likely to achieve higher outcomes
If done correctly, you have measures of your success!
The inability of patients to participate fully in the goalsetting process largely determines the approach taken
by therapists (Leach et al 2009)
SMART
Goals
SMART 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??
SMART goals
S
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, engaging
R
Re-Do, recorded, reviewed, rewardable
(Wade 2009)
S
Specific
- The who/what/when/where/how questions
M Measurable
- What metrics are you using to determine success?
- Formalised outcome measure?
SMART goals – HOW
TO!
A
Achievable
- Does it required learning new skills? New attitudes or understanding?
- Does it require medical improvements?
R
Relevant
- Is it highly valuable for the client or carer?
- Why are we setting this goal now?
T
Time-Limited
- What’s the deadline? Is it realistic timing?
- Short term Vs longer term goals or sub-goals…
SMART Goal E.g’s
The 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!
SMART Goal - TIPS
• As 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 night
• Combination of short-term (success is good!) and more difficult or
longer term goals
• What’s annoying you the most?? If you had a magic wand what
would you change if you could?
Goal Attainment Scale
The 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 initially
Used in DVA funding models
Highly valued in the literature as an outcome measure
Recommended 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
Goal Attainment Scale (GAS) -
Scaling
Scoring 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)
1. Identify the issues that will be the focus of the treatment
GAS:
GAS focuses on those problems, issues or symptoms that the
intervention is expected to change. Eg issues list
2. Translate the selected problems into at least 3 goals
How are
the goals
scaled?
These can be rated in terms of the relevance or importance to the
client.
3. Choose a brief goal title & indicator for each goal
Briefly worded goal. The indicator is the behaviour, future state, skill
or process that represents the goal and can be used to indicate
‘progress’
4. Specify the expected level of outcome for each goal
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 prediction
EG Achieve 6-8 hours of sleep every night for 2 weeks instead of
predicting 7 hours.
5. Specify the ‘somewhat more’ & ‘somewhat less’ levels
GAS:
Discuss and record the levels that are somewhat more or less
favourable.
6. Specify the ‘much more’ & ‘much less’ levels
How are
the goals
scaled?
Discuss and record the levels that are much more and much 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?
GAS Example… & Quick
62 yo man Parkinson’sThink!
Disease
1. Issues: poor balance, poor fine motor control, difficulty with attention/problem solving/memory
2. 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 required
4. 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
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, errors
Think about the potential levels – above and below the expected outcome…
Patient Specific Functional Scale
Developed by Stratford(PSFS)
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-centred
Can be used from individual client’s perspective, but also to collect
data from organisation’s perspective
Patient Specific Functional Scale
(PSFS)
PSFS Method For Use
PSFS
1.Patients 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 Eg & Quick Think…
62 yo man Parkinson’s Disease
Occupational Issues (identified through Ax)
- Difficulty with feeding due to tremor
- Difficulty with tying shoelaces
- Difficulty with writing
- Difficulty using the computer for online banking
PSFS Goal Setting
1. Can use a spoon for my cereal without spilling milk at all
2. Increase speed of tying shoelaces so I can be independent
3. Sign my name with confidence, accept by the bank
Performance score 2/10
Performance score 4/10
Performance score 5/10
Canadian Occupational Performance
The COPM is a client-centred outcome measure for individuals to identify
Measure
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 individualised
COPM 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/
COPM
COPM Method For Use
COPM
1. 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 each
occupation 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 intervention
COPM Eg & Quick Think…
62 yo man Parkinson’s Disease
1.Personal 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
Feeding
Shaving
Computer
Writing
Performance 3
Performance 6
Performance 2
Performance 6
Performance 5
Satisfaction 1
Satisfaction 3
Satisfaction 6
Satisfaction 5
Satisfaction 8
*** What do you focus on for your treatment?? Think about your clinical reasoning… ***
Goal Setting in the
Expectations
Anyone can have, NDIS
and achieve, goals regardless of disability, capacity or situation
HP’s focus on the client’s goals and continually review the client’s goals
Core Funding (supports) Vs Capacity Building Funding (therapy) Vs Capital Funding (equip/mods)
Challenges
Client’s don’t always know what they want to work on or find it hard to understand that they can
improve/progress in different ways
Time pressures
Support Coordinator/Family/Service Providers – differing expectations?!
Strategies
Clear goal setting
Clear transparent communication – verbal and written
Expectation management from the start
Understanding your scope and role as the OT and other stakeholders’ roles
Use of goal setting tools
Goal Setting in the NDIS
Domain -
ACTIVITIES OF DAILY LIVING
Client Goal -
I want to be more independent with ADLs
Goal Setting (!)
Assistance from a support worker to attend to my personal care needs each morning/evening
Assistance 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?
Goal Setting in the NDIS
Domain -
ACTIVITIES OF DAILY LIVING
Client Goal -
I want to be more independent with ADLs
Goal Setting (!)
Assistance from a support worker to attend to my personal care needs each morning/evening
Assistance 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 SMART
Independently 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 days
Use of a Goal Setting Outcome Measure?? GAS / COPM / PSFS
Intervention Plan – Clinical Reasoning
Task specific practice for dressing, ?strategies for cognition, ?exercises for fine motor coordination, liase with PT
Task specific practice with a dosete, ?reminders, visual cues, SV for 7 days prior with prompts, then SV no prompts
Toileting routine, prompts/mobile phone reminders. Work on mobility.
Goal Setting in the NDIS
Domain -
ACTIVITIES OF DAILY LIVING
Client Goal -
I want to be more independent with ADLs
Goal Setting (!)
Assistance from a support worker to attend to my personal care needs each morning/evening
Assistance 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 SMART
Use of a Goal Setting Outcome Measure?? GAS / COPM / PSFS
Intervention Plan – Clinical Reasoning
Goal Setting in the NDIS
Domain -
ACTIVITIES OF DAILY LIVING
Client Goal -
I want to be more independent
Goal Setting (!)
Assistance from a support worker to attend to my personal care needs each morning/evening
Assistance 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 SMART
Use of a Goal Setting Outcome Measure?? GAS / COPM / PSFS
Intervention Plan – Clinical Reasoning
References & Further
Ashford S & Turner-Stokes, L. (2014). Chapter 7: Goal Attainment Scaling (GAS) in adult neurorehabilitation. Handbook of
Rehabilitation Goals Setting. Taylor & Francis, UK.
Reading
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: 10.1080/13638490500235581
Debreceni-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-goals
Grant, 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: 10.1080/09602011.2014.901228
Hefford 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):56-65
Kiresuk 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
References & Further
Leach 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: 10.3109/09638280903036605
Reading
McCue, 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-w
Nicholas 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/10.1177/0269215509103551
https://clik.dva.gov.au/rehabilitation-policy-library/15-goal-attainment-scaling/151-introduction-goal-attainment-scaling
https://www.physio-pedia.com/Patient_Specific_Functional_Scale
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!
Questions?
Sarena Jones
Occupational Therapist
Clinical Supervisor & Consultant
sarena@alliedhealthsupport.com