Collaborative, Patient-Centered Goals Are Key For Home .
Collaborative, Patient-CenteredGoals Are Key forHome Health and HospiceSMART Goals Are a Helpful Modelfor a Patient-Centered Approach
Contents0102Collaborative, Patient-Centered Goals Are Keyfor Home Health and Hospice03Assessing the Patient’s Reality04Using SMART Goals Helps Drive aPatient-Centered Approach05Consider the “5 W’s” (and one “H”)06Specific, Measurable, Achievable, Relevant,Time-Bound07Patient-Centered SMART Goals and Your EMR08The Team ApproachTHORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Collaborative, Patient-Centered Goalsare Key for Home Health and HospiceHome health and hospice care offer both challenges and opportunitiesthat are unique within the healthcare arena. The challenges for clinicianscome both from the patient population they are serving and from thehome care setting itself.Home health and hospice patients are usually older adults with multiplecomorbidities or chronic conditions, and family and caregiver supportnetworks vary drastically. Unlike in acute and long term care settings,these patients often function with real autonomy, including in theircompliance (or noncompliance) with treatment and care plan regimens.We know that patients who are engaged in the goal-setting process andinvested in the outcomes are more likely to adhere to their plan of careand treatment. What patients are willing (and able) to do to accomplish agoal is critical to its achievement, which means that collaborative goalsetting is crucial. Indeed, home health and hospice clinicians must becare partners with their patients, and this partnership must begin at theassessment and care planning stage of the relationship.02THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Assessing the patient’s realityA disease-centered approach may be appropriate for some patients, butit is ill-suited for patients with multiple chronic conditions or comorbidities,or those facing end of life decisions. For home health agency (HHA) andhospice patients, patient-centered care and quality outcomes rely ongoals that are individualized to the patient’s unique needs, preferences,and priorities. A comprehensive assessment must go beyond OASIS(Outcome and Assessment Information Set) or HIS (Hospice Item Set).While the home setting presents distinct challenges, it also offersopportunities for more comprehensive assessment and collaborativegoal-setting. The clinician in the home can help patients identify andarticulate priorities and develop goals based not just on medicaldiagnoses but on the patient’s individual, complex reality. That is, theclinician can consider and evaluate all aspects of the patient’s medical,physical, cognitive, psycho-social, emotional, and spiritual needs andvalues. A patient’s reality can include: 03Medical diagnoses and symptomsMedication requirementsPain management desires and restrictionsPhysical surroundings and environmentPhysical abilities and limitationsCognitive and emotional abilities and limitationsPsycho-social environmentPsycho-social and spiritual needs and restrictionsReligious and/or cultural requirements and restrictionsFamily and caregiver support networksHabits and routinesFinancial and/or legal restrictionsTHORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Using SMART Goals Helps Drive aPatient-Centered ApproachPatient-centered goals should consider the individual’s unique reality.They should be prioritized based on that reality and includeindividualized target dates or time lines. Patient-centered goals canaddress any aspect of a patient’s reality, including: Diagnosis-specific treatment outcomesReduction or maintenance ofsymptomsReduction or maintenance ofpain/suffering Knowledge and understanding of medical conditions orsymptomsMaintenance of/improvement inphysical or cognitive function Improvement in well-being and/or coping skills Maintenance of/increase inindependenceMaintenance of/improvement in quality of life Extension of life expectancy Renewal of hobbies and activities Ability to attend a specific function or eventFamily and caregiver goals must be considered as well. Especially in ahospice or palliative care setting, these may differ significantly from thoseof the patient and/or clinician.04THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Using the SMART goal model is one of the best ways to ensure thatgoals and outcomes are patient-centered and prioritized. “SMART” is anacronym that was first published in 1981 by George T. Doran (“There’s aS.M.A.R.T. way to write management’s goals and objectives”), whodefined it as Specific, Measurable, Assignable, Realistic, and Timerelated. The SMART concept has been around a lot longer, however, andmay have been known as early as the 1940’s-1950’s as a goal-settingtool for business management. Through the years SMART goals havebeen used in business, education, healthcare and personal goal-setting,and the acronym definition has evolved over time to the current Specific,Measurable, Achievable (or Attainable), Relevant, and Time bound.When developing SMART Goals, it is helpful to address the “5 W’s” (andone “H”): WHO must be involved in the progress towards this goal? WHAT does the patient/clinician/caregiver want to accomplish throughthis goal? WHICH aspects of the patient’s reality must be considered in theidentification of and progress towards this goal?WHEN will the goal be accomplished? WHY does the patient/clinician/caregiver want to accomplish this goal(motivation, benefits or broader end-goal)? HOW will progress toward and attainment of the goal (outcome) bemeasured?05THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Patient-centered SMART goals should be:Specific Is the goal clear, concise and complete? Is the goal concrete and measurable? (i.e., “patient will be able to list ” instead of “patient will know”)Does the goal answer the “Who” (patient, clinician or caregiver) and“What”?Measurable Can progress toward the goal be objectively measured and recorded? How will progress be measured? Are there interim steps necessary to the achievement of the goal? (If so, consider breaking it down into smaller interim goals)Does the goal address the “How”?Achievable Is the goal attainable, realistic, and reasonable given the patient’s reality?Does the patient have the knowledge, skills, and ability necessary toachieve the goal?Should the goal be broken down into intermediate steps or interimgoals?Does the goal address the “Which”?Relevant Is the goal relevant to the patient’s reality? Is the goal in keeping with the patient’s priorities and values? Does the goal address the “Why”?Time Bound Does the goal have a clearly defined, specific time-line or target date? Is it possible/realistic to put a target date on the goal? 06(If not, it should be reworked)Is the time-frame realistic and reasonable for this patient?(If not, consider breaking it down into smaller interim goals)Does the goal answer the “When”?THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Patient-centered SMART goals and your EMRYour HHA or hospice EMR (electronic medical record) can be aninvaluable tool for goal-setting and outcomes management.Your system should prompt for goal-setting by diagnosis and comorbidity,and allow additional goal entry based on the clinician’s comprehensiveassessment. Clinicians should be able to identify, record and chart onbehavioral goals, health and well-being goals, and care or service goals.For hospice and palliative care patients, it is crucial that your EMRenable goal setting for caregivers and families as well.07THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Two key components of a SMART goal are measurability and time. YourEMR system should prompt for achievement target dates and facilitateoutcomes measurement charting.The Team ApproachOnce patient goals have been developed, it is crucial that all cliniciansand caregivers understand the documented goals. This is where yourEMR can really help. No matter who identifies or documents a goal, it isavailable to all members of the interdisciplinary care team. Everyone willbe able to view, monitor and verify the patient’s goals and outcomes.This communication and coordination among care providers, based on ashared understanding of patient-centered goals, can directly impactpatient outcomes.08THORNBERRY LTDCollaborative, Patient-Center Goals Are Key for Home Health and Hospice
Collaborative, Patient-Centered Goals are Key for Home Health and Hospice Home health and hospice care offer both challenges and opportunities that are unique within the healthcare arena. The challenges for clinicians come both from the patient population they are servin
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Design Considerations for Collaborative Care The Physical Environment of a Patient-Centered Medical Home The patient-centered medical home is a model of care that seeks to strengthen the physician-patient relationship by replacing episodic care based on illn
Revised July 2017 PCMH CEC Handbook Patient-Centered Medical Home Content Expert Certification Overview The patient-centered medical home (PCMH) is a health care setting that facilitates partnerships between individual patients and their personal clinicians, and when appropriate, the patient’s family. Care is facilitated by registries,
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