Writing goals for our patients can often be challenging, especially for cognition. And our patients aren’t always motivated to improve their memory and other skills. But writing SMART memory goals can actually help improve therapy outcomes. I’m sharing a real-life example to illustrate this benefit.
Free DIRECT download: Writing SMART cognitive goals (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Finding your patient’s motivation is the key.
- SMART goal, defined.
- Writing SMART goals is a win – win – win.
- Patient A: Impaired but not motivated.
- How would you write her goals?
- How I wrote her short and long-term goals.
- Patient A’s SMART memory goals, explained.
- My therapy process and the outcomes.
- Patient A exceeded expectations.
- Related Eat, Speak, & Think posts.
- Give SMART memory goals a try.
Finding your patient’s motivation is the key
The process of gathering information to write SMART goals often allows me to achieve meaningful outcomes with challenging patients. In this post, I’ll talk about one specific patient; I’ll call her Patient A.
Patient A had a memory impairment which was causing some difficulty. But she wasn’t motivated to address those problems in therapy. She had a lot on her plate, and wasn’t excited about adding yet another set of appointments to her calendar.
In the past, I would have picked her up for trial therapy. In my mind, trial therapy is to see if my patient will benefit from therapy. And it also allows some time to teach family some compensatory strategies. But because I now want to write SMART goals, I played detective and found something that motivated her. She participated in therapy and achieved a meaningful outcome.
SMART goal, defined
We probably all know what SMART goals are: Specific, Measurable, Achievable, Relevant, and Time-bound. Easy to say, but not necessarily easy to write. I find that I struggle most with cognitive-communication goals, followed by language goals.
Writing SMART goals is a win – win – win
You as the therapist gain clarity and save time
Writing SMART goals has improved my therapy and reduced wasted time. I don’t know about you, but when I write a vague goal, I often struggle with a lack of clarity. I waste a lot of time re-thinking my patients and planning what to do with them week after week.
But since I’ve been working with my patients and their families to figure out what really bothers them, I’ve find it much easier to plan therapy.
Therapy starts off on the right foot when you’re clear about what you want to accomplish. Planning is easier and faster, as well. Your sessions may be more focused, and it’s obvious when you’ve met your goals.
Your patient is motivated, and everyone’s on the same page
When you’re able to identify the specific, tangible outcome your patient wants from therapy, they feel that you’re helping them in a meaningful way. Your patient understands the goals of therapy and is motivated to achieve those outcomes.
In addition, any medical professional caring for your patient could read your documentation and understand what you’re doing and why. I’ve had several doctors tell me that they find my reports useful because they can understand them. And hopefully, another Speech-Language Pathologist (SLP) could pick up my patient and know what I’m doing and why.
Your employer benefits from happier clients and better therapy
Finally, I believe that writing SMART goals is good for business, although I have to say that I don’t really understand the business side of home health.
At any rate, my sense is that clinicians who write SMART goals may be delivering better results in a more efficient way. So patients may be happier with therapy that is directly tied to their desired outcomes, and clinicians may happier with the increased clarity of purpose. And a business can only benefit from having happy clients and employees.
SMART goals would allow a non-SLP supervisor to understand what we’re doing with our patients and why. And other SLPs could review our documentation and easily judge if therapy was appropriate and effective in achieving meaningful outcomes.
And, sadly, it seems that the contributions that SLPs make aren’t often understood and appreciated. Some employers under-utilize SLPs, which could be improved if they understood ST better.
Patient A: Impaired but not motivated
As always, I’m changing details to protect identity, but this was a real patient I worked with. Patient A was an elderly woman with a non-progressive cognitive impairment who lived with her capable husband. Her forgetfulness caused minor problems, such as frequently misplacing things and asking about the daily schedule repeatedly. Her husband expressed mild annoyance and would feel relieved if I could “fix” her memory problem.
When I did the evaluation, Patient A was not interested in improving her memory to help with those problems. She stated she didn’t really care that she was forgetful because her husband was so helpful.
But you probably see the mismatch between their perspectives. Although things seem tolerably good now, there’s a potential for future problems between Patient A and her husband.
I could teach her husband some compensatory strategies that may help, but I wanted to try to directly help Patient A. I knew that if I tried to directly improve her memory for her husband’s complaints, she probably wouldn’t benefit. So I probed to try to find something that memory was impacting that she cared about. I asked how she spent her leisure time now, about her previous hobbies, and about her family.
I found my “hook” to helping Patient A
The only issue that came up was that she got flustered when she couldn’t name her grandchildren. She stated that she knew them, but that remembering names was hard. I reassured her that this was a common problem, and that I could teach her to remember the names better.
She was interested, so I used that as my “hook” to engage her in learning the memory strategies. I figured that at worst, she would remember at least some of her grandchildren’s names. And at best she would learn strategies that she could choose to apply to other areas.
I made a judgment call that I’d be able to explicitly teach her memory strategies, rather than use spaced retrieval with errorless learning or an external memory aid.
How would you write her goals?
It might be useful to take a moment and write a goal or two for her before looking at mine. There’s no single correct answer, but as long as you have the SMART elements, then I’m sure your goals are fine. And if you disagree with my goals, please share in the comments below. I love learning from you as much as I love sharing what I’m learning.
How I wrote her short and long-term goals
Short-term goals
- Patient A will independently use at least 2 memory encoding strategies during the process of relearning the names of her grandchildren in order to improve memory skills for functional information by 2.9.19.
- Patient A will name at least 4 of 5 grandchildren from memory across two consecutive sessions to improve communication and reduce frustration by 2.9.19.
- Patient A or caregiver will independently verbalize or demonstrate understanding of at least two strategies to compensate for memory loss and to reduce caregiver burden by 2.9.19.
Long-term goals
- Patient A will demonstrate ability to independently use at least two memory strategies with 100 percent accuracy across two sessions so that she may apply these strategies to other learning situations to increase independence and reduce caregiver burden by 2.9.19.
- Patient A will name at least 4 of 5 grandchildren from memory across two consecutive sessions to improve communication and reduce frustration by 2.9.19.
- Patient A or caregiver will independently verbalize or demonstrate understanding of at least two strategies to compensate for memory loss and to reduce caregiver burden by 2.9.19.
A brief explanation of my goals
I captured my direct intervention with Patient A in two goals, because I wanted to make sure she met at least one. I felt sure that I could at a minimum help her relearn her grandchildren’s names. But I wasn’t sure if she would learn to use two strategies independently.
As for goal 3, I wasn’t sure if Patient A would care about the compensatory strategies I was going to teach her husband. For that reason, I worded the goal as “Patient A or caregiver”. This way, I knew I could mark the goal as “met” as long as her husband fulfilled the requirements.
I don’t always have a 1:1 match between short-term and long-term goals. Often, I’ll write two short-term goals that target one long-term goal. And sometimes, my short-term goals match my long-term goals verbatim.
Patient A’s SMART memory goals, explained
Specific
A goal is specific if it states the who, what, where, when, and how of therapy. In this case, the “who” is the Patient A for goals 1 and 2. And for goal 3, the “who” is either Patient A or her husband (or both).
The “what” reflects the specific outcome your patient (and/or family) wants from therapy. In this case, the “what” is learning memory strategies in the context of relearning her grandchildren’s names (goal 1). Goal 2 is actually being successful in relearning at least four names. And goal 3 is Patient A or her husband showing they understand my recommendations to deal with misplacing things and repeatedly asking about the day’s events.
The “where” and “when” are irrelevant for these goals.
For goals 1 and 2, the “how” is that she’s learning to say the names from memory (not naming pictures) by using at least two memory strategies. Further, Patient A will achieve goals 1 and 2 when she’s able to complete the tasks independently. I didn’t want to write the long-term goals “with min cues” since one of the main points of therapy is to reduce the burden on her husband.
Finally, for Goal 3, she or her husband would tell me the strategies without reference to written information or show me that they’ve implemented the strategies.
Measurable
We should have no difficulty recognizing and documenting when we meet our goals. For goal 1, Patient A has to independently use two memory strategies during the process of relearning her grandchildren’s names (even if it’s just during the final session).
As for goal 2, she has to name at least four of her grandchildren in two adjacent sessions for me to consider her goal met.
Finally, for goal 3, either Patient A or her spouse can state the recommendations from memory or show that they’ve implemented them.
Achievable
Our goals have to be realistic for our patients to achieve. If we set the bar too high, they may fail. We can always modify our goals to lower the expectations, but I think it would be bad practice to do that frequently.
On the other hand, if we set the bar too low, our patients may not get much out of therapy. There’s no point in writing long term goals that involve “with min cues” if there isn’t a caregiver willing and able to provide “min cues”. Plus, we should always consider the burden to the caregiver.
In this case, I’m expecting her to learn and use two of the four memory strategies independently (goal 1). And because she had such difficulty naming her grandchildren at the start, I’m setting the criteria at naming 4 of 5 grandchildren (goal 2).
Goal 3 doesn’t require Patient A or her husband to implement the strategies. They may or may not decide to implement the strategies. If they do implement them, they may not feel an urgency to do so during my care. They have a lot of other things going on, and implementing the strategies may take a lower priority. I felt sure that her husband would be able to repeat back the strategies from memory at a different time from when I taught them.
Relevant
Consider the “why” for each goal. Why does your patient or their family want to spend time working on this goal? This should reflect your justification for providing services. Some reasons for “why” might be to improve participation, independence, or safety, to reduce frustration, or to reduce caregiver burden.
Patient A’s own desired outcome from therapy is directly expressed in goal 2. She’s embarrassed when she can’t remember her grandchildren’s names. In conversation, she often uses the wrong name which can be confusing.
I feel that Goal 1 is relevant because it’s achieved completely in the context of Goal 2 and it addresses her husband’s wish that Patient A’s memory were better.
And Goal 3 is directly relevant to her husband’s complaints. The intention is to reduce his minor annoyance at having to look for his wife’s belongings and answer her questions repeatedly.
Time-bound
I made Patient A’s goals time-bound by designating a specific date for each one. For simplicity, I used the same end date for all of these goals.
In general, my short-term goals range from one to four weeks from the time of writing the goals, whereas my long-term goals generally are one to two months.
Putting an end-date on the goal doesn’t lock you into that time-frame, however. We always have the option of modifying all aspects of a goal, which is a skilled intervention in and of itself.
My therapy process and the outcomes
I introduced the WRAP memory strategies
I taught her the WRAP memory strategies (write it down, repeat it, associate it, picture it). In this case, I taught repetitive writing as a study method to internalize the information. I provided the strategies in writing and left them sitting out as a reference.
How I helped her learn
I gave her a whiteboard and asked her to start with one grandchild’s name and write it 10 times while saying it aloud. I also asked her to think of that grandchild as she was saying their name.
Then I had her look away and answer a working memory question as a distractor task (such as “tell me the days of the week in backwards order”). Next, I assessed short-term recall by asking her to name the grandchild she had just written. I reinforced her recall of the name after making her think about something a little hard.
Finally, I challenged her to reflect on the strategies that gave her that success. I turned the whiteboard over and hid the memory strategies. Then I asked her what she could do to remember the next name on the list. My intent was to help her internalize the strategies.
At the start she could name one or two strategies independently. I presented the strategy list again and asked her to tell me the four strategies. Then we repeated the entire process with the next grandchild. When the time came to assess her short-term memory, I asked for the two names she had studied that day. And then after reflecting on the strategies, we began on the third name.
Teaching compensatory strategies
While I taught her the memory strategies by helping her to relearn her grandchildren’s names, I was also educating her and her spouse about strategies that could help with the other issues (goal 3). I taught the common strategy of dedicating a specific spot as a “home” for commonly-used or important items.
For the other issue, I took into account where Patient A spent most of her time. No sense writing down the day’s activities on the fridge if she rarely walks into the kitchen. Since she spent most of her time in her armchair in the living room, I suggested writing down the day’s events on a whiteboard and propping it up where she could see it. I provided supplies that I’d bought at a dollar store.
Patient A exceeded expectations
Patient A practiced learning those names on her own every day that first week. When I came back for the third routine visit, she had relearned the names of all five of her grandchildren. In addition, she had started learning the names of her great-grandchildren. She was really proud of herself, and I was happy that she had learned how to study and remember information that was important to her.
Even though she wasn’t interested in memory therapy at the start of my evaluation, she would have participated if I had pushed because she was amiable and her husband was encouraging. But I knew the results would be lackluster. So I dug a little and found a specific problem that she was motivated to improve.
As a result, she relearned information that was important to her, and she learned the memory strategies which she was already applying to a new set of information. In addition, I was able to provide some helpful ideas to her and her husband to address the other memory complaints. She and her husband both felt that therapy was successful/worthwhile.
Related Eat, Speak, & Think posts
- 5 easy steps to remember names.
- 31 creative ways you can remember to take your medication.
- SLPs play important role in home health medication education.
- Treating cognition in the real world.
- Collaborative goal-setting to identify meaningful cognitive goals.
- Goal Attainment Scaling tutorial.
Give SMART memory goals a try
I’ll be honest, my goals aren’t always as specific as they could be. Sometimes when I pick someone up, I’m sure I can help them, but we haven’t quite identified the specific desired outcome or I’m not quite sure which approach will be best. So I write a more general goal and then target my therapy as it becomes clear to me.
But I feel confident that trying to write goals that focus exactly on what my patients want to achieve from therapy has been a tremendous help and time-saver for me. If you’re not already writing SMART memory goals, I’d encourage you to give it a try.
Free DIRECT download: Writing SMART cognitive goals (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by William Krause 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.
excellent post/ information!!!! Lisa you never cease to amaze this veteran SLP! thank you for great resources.
Thanks so much, KMW!! Happy you found it useful!