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CHHS17/298

Canberra Hospital and Health ServicesClinical Procedure Family Meetings and/or Goal Setting Meetings and Case Conferences for Rehabilitation ServicesContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Goal Setting Meeting..............................................................................................2

Procedures for Goal Setting Meetings..................................................................................2

Outcomes to a GSM, or review GSM, include:......................................................................3

Documentation:....................................................................................................................3

Section 2 – Case Conference.....................................................................................................3

Procedures for Case Conferences.........................................................................................3

Documentation.....................................................................................................................4

Section 3 – Family Meeting.......................................................................................................5

Procedures for Family Meetings...........................................................................................5

Documentation.....................................................................................................................5

Related Policies, Procedures, Guidelines and Legislation.........................................................6

Definition of Terms...................................................................................................................6

Search Terms............................................................................................................................ 6

Attachments..............................................................................................................................7

Attachment A: A Guide to Goal Setting Meetings (for staff).................................................8

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

The purpose of this document is to provide a clear process: For facilitating and accurately documenting goal setting meetings (GSM), case

conferences and family meetings. To assist with timely and accurate communication of agreed outcomes and other

relevant information to patients/family/carers.

Back to Table of Contents

Scope

This procedure applies to Canberra Hospital and Health Services (CHHS) staff attending goal setting meetings, case conferences and family meetings in the inpatient rehabilitation setting.

This procedure applies to CHHS staff working within their scope of practice: Medical Officers Nurses Allied Health professionals Student under direct supervision


Section 1 – Goal Setting Meeting

The aims of a goal setting meeting are: The patient will set specific, measurable, achievable, realistic, timely (SMART) goals for

their rehabilitation. The patient and multidisciplinary team review the patient’s goals and their progress

towards these goals.

Procedures for Goal Setting Meetings The patient’s first goal setting meeting is scheduled for the patient by their nominated key worker. A patient’s key worker is decided upon by the treating team at a white board meeting, which are held twice a week. The patient’s goal setting meeting is to occur within 5 working days of the patient’s admission to rehabilitation.

The key worker provides the patient with the consumer handout “Goal Setting Meeting Information”, located on the policy register on SharePoint. The patient is encouraged to invite their family/significant others to the meeting if they wish. Only when relevant will the key worker directly invite anyone in addition to the patient, for example, in the presence of a significant cognitive issue or language barrier.



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A review of a patient’s GSM may be scheduled if required. This will be arranged at an appropriate time to the patient and team.

Outcomes to a GSM, or review GSM, include: clear goals as identified by the patient, their family and the team realistic timeframes Australian National Subacute and Non-acute Patient (AN-SNAP) classification dates are

discussed.

Documentation: The Rehabilitation Goal Setting - eNote form is accessible on the clinical forms register

on SharePoint. Each discipline is responsible for completing their required section(s) in the

Rehabilitation Goal Setting form. The key worker is responsible for ensuring the Rehabilitation Goal Setting form is signed

by the relevant staff member(s) and patient. The key worker is responsible for giving a copy of the Rehabilitation Goal Setting form to

the patient and placing a copy on the patient’s medical record.

See Attachment A: A Guide to Goal Setting Meetings (for staff)


Section 2 – Case Conference

The aims of a Case Conference are: Review of the patient’s progress against their identified goals, from their GSM. Discuss any issues or complexities that may be impacting on the patient’s rehabilitation

and subsequent discharge. Discuss any issues that may impact on other therapies or the patient’s daily activities.

Procedures for Case ConferencesCase conferences are held weekly and are attended by members of the allied health, nursing and medical teams. The meeting follows the Case Conference pro forma, the Sub-Acute Multidisciplinary Management Plan, available on the clinical forms register on SharePoint. The team discusses the patient’s progress against the identified goals and in five functional domains: Health and Wellbeing, Mobility, Activities of Daily Living, Communication and Cognition and Community. Each domain is multi-disciplinary, and any member of the treating team can contribute towards discussion on achieving patient goals within these domains.

Other topics that can be discussed include: Falls risks and action plans Potential barriers to discharge AN-SNAP date. This is calculated from the latest functional independence measure

(FIM) score and Australasian Rehabilitation Organisational Centre (AROC) data.Doc Number Version Issued Review Date Area Responsible PageCHHS17/298 1 07/12/2017 01/12/2022 RACC 3 of 9


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Responsibilities of the Rehabilitation Care Co-ordinator (RCC) at Case Conference To chair Case Conference. To facilitate discussion and maintain the scheduled format of functional domains. Maintain flow of meeting and time management. Encourage all members to have input. To check there are no further issues in each functional domain. Allocate actions and persons responsible. Discuss, update and document AN-SNAP date.

Responsibilities of Team Members at Case Conference Provide clear, concise information, outlining the progress of each patient against their

identified goals. Case Conference documentation is kept electronically on the Q Drive: RACC\Common\

Case Conference 12B folder. Document accurate information prior to Case Conference. Ensure actions allocated are completed. Provide a timely handover when unable to attend. Discuss any changes to AN-SNAP date.

Documentation Each patient has a Sub-Acute Multidisciplinary Management Plan, located on the Q

Drive: RACC\Common\Case Conference 12B folder. This documentation is commonly referred to a Case Conference Documentation.

The RCC’s ensure a new Sub-Acute Multidisciplinary Management Plan for each patient is available on the Q Drive: RACC\Common\Case Conference 12B folder, each week.

Administration support set up the laptop for Case Conference. Each discipline is responsible for updating Case Conference documentation prior to Case

Conference each week. At the end of Case Conference, RCC’s are responsible for signing and placing a copy of

the plan on the patient’s medical record each week. RCC’s explain to the patient the outcomes from the Case Conference meeting each

week.

Detailed discussion should be directed towards issues and complexities relating to interruptions of the patient’s rehabilitation progress or timely discharge.

Specific details of individual therapy sub-goals or the content of therapy plans is not necessary in case conference discussions.

Discussions from the case conference may inform the CHHS Long Stay Report.


Section 3 – Family Meeting

The aims of a Family Meeting are to:Doc Number Version Issued Review Date Area Responsible PageCHHS17/298 1 07/12/2017 01/12/2022 RACC 4 of 9


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Share information with the patient and/or their family. Facilitate discharge planning. Assist effective decision-making between the client, family and/or the treating team.

Procedures for Family Meetings A Family Meeting is scheduled when identified by the treating team or requested by the client or family member. Usually the patient’s social worker organises the meeting but not always. Family meetings will not be scheduled routinely for all patients. Potential invitees will be discussed with the patient directly and where appropriate with their family. External supports and other significant people may also be invited to a family meeting.

The meeting will follow the Health Professional Family Meeting form, which is available on the clinical forms register on SharePoint. A family meeting provides an information sharing opportunity rotated through each discipline, followed by questions, and time for discussion and response to questions from the patient and/or family.

Responsibilities of the Family Meeting Organiser (Social Worker or delegate) Discuss the purpose of the family meeting with the patient and/or family. With the patient’s consent, invite significant family members. Confirm the family meeting time with the patient and/or family and the members of the

patient’s treating team. Record the meeting date and time on client’s bed side white board, patient journey

board, nurse’s diary and in client’s medical record. Prior to the family meeting, obtain written report from staff who are unable to attend

the meeting. Facilitate the meeting and keep it to time. Verbally summarise the outcomes of the meeting at the end of the family meeting.

Responsibilities of Team Members Come prepared and on time. Discuss with the patient prior to the family meeting issues or concerns. If you are unable to attend the family meeting, a written report is to be provided to the

meeting facilitator the day before the meeting. Complete documentation after the Family Meeting.

Documentation Family meeting documentation for Ward 12B is kept electronically on the Q Drive RACC\

Common\Case Conference 12B folder. The meeting facilitator ensures an electronic copy of the Health Professional Family

Meeting form is available on the Q Drive RACC\Common\Case Conference 12B folder common drive.

Each discipline is responsible for completing their relevant section of the Health Professional Family Meeting form, within two days of the Family Meeting.



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A copy of the signed and completed Health Professional Family Meeting form will be provided to family/carer by the nominated health professional as soon as practicable, following the meeting (target is two working days).


Related Policies, Procedures, Guidelines and Legislation

Policies Consent and Treatment Policy Language Services Policy

Procedures Clinical Record Documentation SOP Language Services – Interpreters Procedure

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


Definition of Terms

Functional Independent Measure (FIM): An assessment of the severity of patient disability.

Key Worker: The key worker is any member of the treating team. A patient’s key worker is allocated at the white board meetings.Nominated Health Professional: The nominated health professional is a member of the team who agrees to undertake a task decided upon at a meeting. This may include providing information to a patient or family member or following up a particular request.


Search Terms

Goal setting meetings, Rehabilitation, Case conferences, Family meetings


Attachments

Attachment A: A Guide to Goal Setting Meetings (for staff)



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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 15/11/17 Complete Review Todd Kaye, DAH, RACC CHHS Policy

Committee

This document supersedes the following: Document Number Document NameCHHS13/464 Documentation and Processes for Family Meetings and/or Goal Setting

Meetings



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Attachment A: A Guide to Goal Setting Meetings (for staff)

Goal Setting Meetings:

FormatThe meeting will follow “A Guide to Goal Setting Meetings” and the patient will be encouraged to identify their goals in any of the relevant five domains of rehabilitation. Each of the five domains of rehabilitation are multi-disciplinary, and any therapist can contribute towards achieving patient goals within these domains.

Setting Goals and plansGoals: “What do you want to be able to do?”

Goals are set by the patient, and are relevant to their rehabilitation needs. They should be relevant to the patient’s discharge needs or wants and related to their function.

Goals are not therapy plans. Therapy plans are designed to assist the patient to achieve their goals. Goals may be short term achievements whilst an inpatient and can also include goals which may be longer term and followed up in the community.

Examples of patient goals: Manage my pain and understand my medication. Walk by myself around the house. Go to the toilet by myself. Talk on the phone. Clean my house when I go home.

Plans: “What do you need to do to reach your goals?”

Discussion of plans enables the patient to understand what they will be doing in therapy, and why, and how this relates to their goals. Plans may include: the content of the therapy (general) and the frequency.

Examples

Goal: Manage my pain and understand my medication. Plan: Pain management via medication and psychological strategies. Education by doctor or pharmacist within (date). Review medications weekly on the doctor’s round.

Goal: Walk by myself around the house.Plan: Attend physiotherapy twice daily. Leg strengthening exercises.



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Practice walking on the treadmill and over the ground. (link to other goals – e.g. standing up and balance).

Goal: Go to the toilet by myself.Plan: Practice transfers, both in therapy and in the toilet. Practice components of this activity e.g. attend toileting hygiene or adjusting clothing.

Goal: Talk on the phone. Plan: Attend therapy daily to practice (description of task). Do my homework.

Goal: Clean my house when I go home. Plan: Review my progress against other goals and identify need for assistance. Discuss my needs for assistance with the team. Complete application form with assistance from the team.

Each therapist should assist the patient to identify generalised goals, ensuring that potentially relevant goals are not forgotten.

The therapists should indicate at the goal setting meeting how they intend to work with the patient towards achieving these goals, and an estimated timeframe.

Any specific sub-goals and discipline specific details of therapy to achieve the patient’s overall goals should be discussed with the patient by each therapist within therapy sessions and documented in the health record separate to the goal setting document.

If goals appear unrealistic (due to pathology or prognosis), the therapist should assist the patient to set a sub-goal that would be the first step in working towards the larger patient goal. This should be accompanied by a timeframe of trialled therapy to enable a review of that goal. If the therapist believes the patient’s goals are unrealistic, discussion and education with the patient within that therapy should occur. If there is no progress towards the identified sub-goal, the therapist may consider discontinuing therapy towards that goal at the review goal setting meeting.



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