Goal Development Process

GOAL DEVELOPMENT PROCESS OVERVIEW

• Source: Shenandoah University, Lacy Woods Hochkammer, OTD, OTR/L, Division of Occupational Therapy.

OBJECTIVES

• Discuss the goal development process as a whole.
• Understand how discharge planning and goal development relate to one another.

REVIEW OF THE GOAL-SETTING PROCESS

• Evaluation
  • Client/caregiver interview.
  • Assessment.
  • Observation of occupational performance.
• Goal development in collaboration with client/caregiver based on evaluation results & discharge plan.
• Treatment
  • Working toward goals.
  • Consistent evaluation of progress.
  • Adjustment of goals if needed.
• Discharge
  • Once goals have been met, client/caregiver/facility in agreement.

A BIT ABOUT DISCHARGE PLANNING

• Discharge (D/C) planning starts at initial evaluation.
• How/why?
  • During your eval, you are identifying strengths & limitations related to occupational performance.
• The ultimate goals: of eval = the ultimate goal of treatment = what happens when they don’t need you anymore?
• In short, from the time of the initial evaluation, you are working toward DISCHARGE.

WRITING GOALS WITH D/C IN MIND

• SMART framework:
  • Significant, Measurable, Achievable, Related, Time-limited.
• Additional notes:
  • Achievable within the time they will be in your specific setting (acute care hospital, acute rehab, SNF, outpatient, etc.).
  • Related to what they want and NEED to be able to do upon discharge.
• Example: Joelle is admitted to an acute psychiatric unit due to a suicidal attempt. The d/c recommendation is for a halfway house and partial hospitalization program (PHP).
  • STG: In 3 days, Joelle will verbally identify 2 personal strategies, tools, or resources to implement as part of her wellness toolbox with supervision.
  • Notation: 3 days is represented as $3\,\text{days}$.

WRITING GOALS WITH D/C IN MIND (CONTINUED)

• Ensure goals are aligned with post-therapy environment (d/c environment).
• Reviewing client needs and resources.
• Align goals with resources available at d/c.
• Facilitate a smooth transition to post-d/c life (e.g., home, supported living, outpatient care, etc.).
• Example of incorrect goal-setting (to illustrate common mistake):
  • Trent is receiving OT services at a community mental health center due to alcoholism and multiple DUIs. He has lost his license.
  • LTG (incorrect): Trent will secure full-time employment in an area of interest independently in $8\ \text{weeks}$.

MENTAL HEALTH GOALS

• Client-Centered
  • Reflect the client’s personal values, preferences, & recovery priorities.
  • Focus on meaning and sources of motivation when possible.
• Function-Oriented
  • Focus on improving participation in meaningful occupations.
• Behavioral
  • Be specific & describe observable behaviors (e.g., "participate in a group conversation with peers for 8 minutes without interruption").
• Measurable
  • Make goals quantifiable (e.g., "complete mindfulness exercises" or "complete a 5-minute mindfulness activity independently 3x/week").
  • Example: $\text{complete a 5-minute mindfulness activity independently 3x/week}$
• Achievable & Realistic
  • Attainable within the client’s abilities & given their resources.
• Collaborative
  • Develop with input of the client and other HCPs (social workers, psychiatrists, etc.).

CONDITION EXAMPLES (MENTAL HEALTH) – PART 1

• Schizophrenia with auditory hallucinations
  • Evaluate to identify impact.
  • Possibilities: decreased social participation, difficulty obtaining work, difficulty sequencing tasks (meal prep, self-care, etc.).
  • Example goal: $\text{Client will complete a 3-step meal prep task with minimal assistance using compensatory strategies and environmental modifications prn}.$
• Postpartum OCD & intrusive thoughts
  • Evaluate to identify impact.
  • Possibilities: decreased self-efficacy with caregiving, impaired ability to complete self-care tasks, decreased attachment and bonding with infant.
  • Example goal: $\text{Client will feed her baby 1\text{/day} with supervision utilizing auditory affirmations prn}.$

CONDITION EXAMPLES (MENTAL HEALTH) – PART 2

• Group of teenage clients with ASD and poor social awareness
  • Evaluate to identify impact.
  • Possibilities: decreased ability to interact with peers, isolation, poor self-awareness.
  • Example goal: STG: Clients will correctly correlate the facial expressions of a peer to possible feelings/emotions during $\frac{1}{3}$ role-play scenarios with supervision.
• Chronic back pain and depression
  • Evaluate to identify impact.
  • Possibilities: decreased socialization, self-isolation, decreased self-care participation.
  • Example goal: $\text{Client will shower independently 2\text{/week} using AE/AD/DME/environmental modifications prn}.$

MENTAL HEALTH GOALS (FOCUS AREAS)

• Focus on behavioral and cognitive aspects of function (vs. physical rehabilitation).
• Development of routines, coping mechanisms, social skills, emotional regulation strategies, cognitive skills (executive functioning).
• Aim to improve: self-esteem, interpersonal relationships, overall mental well-being.
• May include self-reports of mood, use of coping strategies, and/or quality of social participation.
• Roles & Routines.

COMMON PROBLEMS & SOLUTIONS WHEN WRITING MENTAL HEALTH GOALS

• PROBLEM → SOLUTION
• Vague/unmeasurable goals
  • Too broad or unclear e.g., "improve coping skills" or "reduce anxiety".
  • Solution: Use specific, measurable terms e.g., "use breathing exercises to manage anxiety $75\%$ of opportunities".
• Lack of Cultural & Personal factors
  • Failing to consider cultural background or personal values.
  • Solution: Ask the client to describe personal meaning and values. Set goals accordingly.
• Unrealistic expectations
  • Too ambitious or not aligned with client abilities.
  • Solution: Break large goals into smaller, achievable steps and consider client’s resources, support systems, and readiness for change.
• Poor Alignment with Context/Environment
  • Failing to consider client’s discharge setting or living situation.
  • Solution: Align goals with the context (home, community, supervision/support available).
• Hyper-focus on symptoms
  • Focusing only on reducing symptoms (vs. function).
  • Solution: Focus on meaningful outcomes, e.g., engage in at least one leisure activity per day to support mood regulation.

SUMMARY

• Goal development starts with the initial evaluation.
• Goals should be written & updated in accordance with the discharge plan.
• Every goal must be observable & measurable.

REFERENCES

• AOTA (2020). Occupational Therapy Practice Framework. American Journal of Occupational Therapy, 74(2).
• Gateley, C.A. & Borcherding, S. (2017). Documentation manual for occupational therapy: writing SOAP notes, 4th 3d. Thorofare, NJ: Slack