Collaborative goal-setting takes a little extra time at the start, but results in some pretty big pay-offs. Here I write about how I collaborate with patients and/or their families to identify meaningful cognitive-communication goals.
Free DIRECT download: Collaborative goal-setting for cognition (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- What is collaborative goal-setting?
- Barriers to collaborative goal-setting.
- Making the time to collaborate saves time going forward.
- How to make the time.
- Allow your patient to talk first.
- What if you still don’t have a goal?
- Final steps in collaborative goal-setting.
- Writing SMART therapy goals.
- Related Eat, Speak, & Think posts.
- What are your tips for collaborative goal-setting?
What is collaborative goal-setting?
Collaborative goal-setting is the process of supporting people in developing meaningful goals for therapy. Ideally, the patient (or their family) would take the lead in identifying specific outcomes they want to see.
The World Health Organization created the International Classification of Functioning, Disability and Health (ICF), which was ratified in 2001. The ICF recommends we look beyond impairments to the person’s actual activity and participation, while considering environmental and personal factors.
ASHA provides examples of functional goal writing using the ICF, including this one for dementia.
Barriers to collaborative goal-setting
If we’re lucky, our patient (or their family) will have clear ideas about what they want to gain from speech therapy. When our patients have a clear goal, collaborative goal-setting is pretty easy.
But we may run into situations where it’s hard to identify personalized functional goals. When asked, some people can only say “I want a better memory for everything” or “I can’t remember what I’m having trouble with. That’s the problem!”
There are many barriers to setting meaningful life participation goals, including:
- Not having time for the discussion.
- Family and friends aren’t available.
- Patient and family can’t report specific activities they want to improve.
- The patient and family have unrealistic expectations.
- Patient seems content watching TV all day.
- Lack of motivation.
Making the time to collaborate saves time going forward
I’ve learned the hard way that writing goals based on my initial observations and assessment results leads to problems for me and for my patient.
Writing impairment-based goals led to these problems:
- Having too many short-term goals to address effectively.
- Longer sessions, often an hour or more.
- Small gains in skills at re-assessment.
- Little improvement in actual day-to-day participation.
- Less-than-enthusiastic buy-in from patients.
- Longer preparation and documentation time for each session.
My mistake was in thinking that working on discrete skills would automatically result in improvement in performance with daily activities.
Improving function (attention, memory, etc) does not mean that a person would then be able to resume participation in their desired activities. And it’s not necessary to treat every impaired skill for the patient to get the results they want.
The key to effective therapy is finding out what really matters to our patients.
Benefits of collaborative goal-setting
Making the time to talk to my patient and at least one person important in their life provides a huge return on investment. In other words, it saves time in the long run and leads to better outcomes.
Supporting my patient in setting goals for therapy has many benefits:
- Patient and family are highly motivated.
- More likely to complete assignments outside of therapy.
- Much more likely to see real-world improvements at re-assessment.
- Shorter, more-focused sessions.
- Fewer short-term goals to report on.
How to make the time
You can gather information before sitting down with your patient by using your powers of observation. Take advantage of every opportunity, for instance:
- Pay attention during the initial phone call to schedule the assessment.
- Any issues in communication or setting the appointment?
- Did your patient voice any relevant complaints?
- If you’re talking to a family member, take a minute to ask about recent cognitive changes.
- Read the patient’s chart, especially the clinical summaries by other disciplines.
- Email your team members who are already working with the patient. What cognitive challenges are they noticing?
- Was the patient expecting you when you knocked on the door?
- Is the home organized?
- How does your patient handle distractions?
By the time I sit down in my patient’s house, I’ve already gathered a fair bit of information to help me understand how my patient is performing.
Beyond this, I make the time for collaborative goal-setting by making it a priority. I don’t start a standardized assessment until I at least have a general idea what my patient wants out of therapy. If the family isn’t present, I’ll call them during the session or later in the day.
Allow your patient to talk first
Why you shouldn’t share your ideas for therapy first
Even though we generally have a good idea what the problems are when we walk in, it’s very important that we don’t share our ideas.
I want my patient (or family) to have the opportunity to share their thoughts, feelings, and desires regarding the difficulty they’re seeing in their life.
Even though I view myself as an equal team member with my patient and their family, they almost certainly view me as an expert or someone with some authority. I don’t want my ideas to inhibit what they may otherwise share.
Invite your patient (and family) to talk
After I’ve introduced myself and described in general terms what I do, I ask them to tell me about any concerns they have. Often, my patients tell me about all their concerns, whether or not they’re related to speech pathology.
So I just let them talk. I’ve learned that if I try to steer the conversation, they may stop sharing.
Benefits of just listening
Just by listening, you can learn:
- What matters to them (crucial for setting goals).
- Which family and friends are supportive.
- The challenges they see.
- Potential barriers to participating in therapy.
- Some insight into their memory and reasoning skills.
- An understanding of their awareness of their own deficits.
Listening also goes a long way to establishing rapport, because it’s not often that a medical professional takes the time to listen while a patient talks at length.
When a person feels like you’re paying attention to them and trying to find a way to help them, trust begins to grow. This not only helps the goal-setting process, but also increases the likelihood that they’ll try your recommendations.
Sometimes by this point, I’ve found an identifiable goal that we can explicitly discuss and agree upon.
What if you still don’t have a goal?
Often, I need to dig a little deeper. Maybe the main concerns they mentioned aren’t related to speech pathology, or maybe they don’t have much to say. Some people can only say that they want a better memory.
Ask open-ended questions
Depending on what I’ve already learned, I may ask an open-ended question, such as:
- How would your life be different if you had a better memory?
- What do you need to be able to do that you can’t do now?
- How well are you managing your day-to-day activities?
- What would you like to be able to do?
- How are things going for you in terms of communicating with your family?
Consider life roles
When I’m probing for information, I’ll consider different aspects of life participation, such as:
- Life roles: spouse, parent, child, friend, community member, employee, volunteer.
- Responsibilities: paying bills, making appointments, shopping, handling the mail, laundry, cooking, medication management.
- Leisure activities/hobbies.
This discussion may spill over into the next session
We have to save time during the initial session to at least start a standardized assessment, fill out some paperwork, and call the doctor.
If we’re running out of time, I call a halt to the conversation and ask them to think it over until the next session.
Then, based on what I’ve already learned, I’ll select an assessment tool and start testing.
Final steps in setting collaborative goals
- Complete the standardized assessment to learn strengths and weaknesses.
- Help them understand their profile and which goals may be quicker to address.
- Allow your patient to pick the most motivating goals to work on.
- Identify people who may be able to help patient with assignments.
- Determine if your patient is willing to use technology in therapy (as appropriate).
- If multiple therapy approaches are possible, ask your patient which they’d like to try.
The assessment and goal-setting process may take two or three sessions, but I’ve found that it’s time well spent.
At this point, you might be ready to jump into therapy. However, in my experience, two problems arise from time-to-time.
Problem 1: Too many goals
Our patients may have several goals they want to achieve. In my practice, I’ve found that therapy is most effective if we focus on one or two goals at a time.
So in this case, I’ll help them pick the most motivating one(s).
Problem 2: Goals seem unreasonable
Sometimes people set goals that may seem unreasonable. However, I’m not going to tell my patient that they’re shooting for the moon.
Instead, I’ll work with them to identify an intermediate step, and that’s what I’ll write as my long-term goal. Then we’ll come up with a smaller, short-term goal.
This way, we’re still working towards my patient’s desired outcome, even though I don’t think they’ll achieve it. Because even after 10 years of experience, people still surprise me with what they can achieve when they’re motivated and have support!
Writing SMART therapy goals
I often get asked to share more about writing goals. Writing SMART therapy goals is easy when I’ve finished the assessment and collaborative goal-setting process by the end of the first session. I just make sure they are”
- Specific.
- Measurable.
- Achievable.
- Relevant.
- Time-bound.
The main content of these goals were determined by the patients themselves. The patient will:
- Demonstrate ability to correctly recall and employ correct sequence of steps for transitioning between sitting to walking with cane on 5 of 5 trials independently to improve safety and independence by [date].
- Name at least 4 of 5 grandchildren from memory across two consecutive sessions to improve communication and reduce frustration by [date].
- Independently enter 3 of 3 appointments into electronic calendar with 100% accuracy to improve time management and reduce frustration by [date].
Here are some other life participation targets my patients have chosen:
- Using the clock, calendar, TV remote, or cell phone.
- Taking medications on time.
- Going to the dining hall or planned leisure activities on time.
- Sending email to grandchildren.
- Remembering to use a cane or walker.
- Enjoying reading again.
- Remembering information: names, birthdays, current age, current year, current president.
- Consistently using a chin tuck with thin liquids.
If goal-setting carries over into the next session
If I don’t have a good idea what my life participation goal will be, I’ll write more general goals. For example, the patient will:
- Complete cognitive communication assessment with further goals to be determined as indicated by [date].
- Demonstrate ability to use 2 recommended strategies independently while completing two memory exercises with 80% accuracy independently to improve memory for functional tasks by [date].
The focus of short term goal #2 is to teach my patient to use memory strategies. It’s possible that once we finish the assessment and collaborative goal-setting that this goal will still apply. “Memory exercises” can apply to anything, whether it’s a worksheet or remembering the steps to enter a new appointment in a digital calendar.
I’ll be honest and say that I generally don’t re-write my general goals, as long as they cover whatever life participation goals we end up targeting.
Related Eat, Speak, & Think posts
- Goal Attainment Scaling tutorial.
- Assess readiness to change for better therapy outcomes.
- How to plan cognitive therapy with 6 questions.
- Writing SMART memory goals for a reluctant patient.
- 7 tips to benefit your home health patients and minimize your workload.
What are your tips for collaborative goal-setting?
Collaborative goal-setting is relatively new to me. I can confidently say that it’s made a huge difference in my practice over the past couple of years. But I’m sure I could improve my process.
Please share what you’ve found helpful! And if you’re not approaching goal-writing in this way, consider giving it a try.
Free DIRECT download: Collaborative goal-setting for cognition (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Amy Hirschi on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
I enjoyed this article! Thank you!
Thank you! And you’re welcome 🙂