sally fields & lynne farrar, gold coast health service district - increasing participation...
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Sally Fields, Senior Occupational Therapist and Lynne Farrar, Senior Social Worker, Transition Care Program, Community, Subacute and Aged Services, Gold Coast Health Service District delivered the presentation at the Transition Care: Improving Outcomes for Older People Conference 2013. The Transition Care: Improving Outcomes for Older People Conference explores a combination of residential and community transition care programs. It also features industry professionals' experiences in transitional aged care, including the challenges and successes of their work. For more information about the event, please visit: http://www.communitycareconferences.com.au/transitioncareconference13TRANSCRIPT
Increasing participation through a
client-centred goal-setting process
Sally Fields, Senior Occupational Therapist
Lynne Farrar, Senior Social Worker
Transition Care Program, Gold Coast Hospital & Health Service
Outline
Why we undertook this review
Application of quality cycle to process
ICF model
Client-centred practice
Goal-setting
Practical application in our service
Why?
Improving client outcomes
Maximising client participation
Strengthening client-centred practice
Streamlining goal-setting and review
process
Increased client engagement
Service snapshot
Gold Coast Transition Care Program
Provides 96 packages of care –
14 residential, 82 community packages
Team includes Rehab Consultant, CN, PT,
OT, DT, SP, SW, Psych, Pharmacist, Welfare
Officer, AHA
Brokered PCW services, transport,
equipment loan, podiatry, some nursing
services
Asking the question
“Is our goal-setting process client-centred,
and are we utilising a coordinated, inter-
disciplinary approach to empower active
client participation?”
The quality cycle
Process
Documentation audit O
Literature review P
Form development & trial D
Feedback and review S
Further improvements A
Documentation audit
Single discipline input
Impairment focused
Clients not engaged
Lack of focus and rigor
Inconsistent documentation
Documentation audit
Review of the literature
International Classification of Functioning,
Disability, and Health (ICF) 1
International Classification of Functioning,
Disability, and Health (ICF)
“Provide a unified and standard language and framework for the description of health and health-related states in order to improve communication between different users…” 1
Participation versus handicap
A focus on participation challenges us to find ways for people to do the things they need to do while they recover 2
Importance of contextual factors
Participation in older people
Majority of older adults experience
participation restriction in their daily lives
80% of participants reported participation
restriction in at least one area of their life 3
Participation & quality of life
Participation is connected to quality of life 4
Loss of participation increases psychological
distress and reduces wellbeing 4
Client participation in goal-setting
Practical use of the ICF
As a framework 5
As a reference 5
As a theoretical basis 6
Client-centred practice 7
Acknowledges client strengths and client
choice
Provides flexibility and values individuality
Enablement
Accessibility
Respect for diversity
Client-centred practice
Provides the client with power 8
Enables clients to become active partners 9
Needs to be incorporated into the goal-setting
process
Outcomes of client-centred practice 10
Respectful & supportive services ➠ Improved satisfaction & adherance
Information exchange ➠ Improved functional outcome
Partnership/enabling ➠ Improved client participation
Individualised intervention ➠ Improved client self-efficacy
Client-centred outcomes
Measure outcomes that are meaningful to
clients 11
Adopting a client-centred approach leads to
increased participation 12
Participation measures 11
Client-centred documentation
Principles of client-centred documentation 13
Client focused
Interdisciplinary
Goal oriented
Documentation should include 13
Client’s concerns
Client’s desired outcomes
Evaluation forms
Need reliable evaluative measurement tools
Client-centred rehabilitation
Aims to enable clients to live lives that are physically, materially & socially fulfilling 11
Inpatient rehabilitation focuses on acquisition of motor skills in order for discharge 11
The extent to which goals are truly jointly set with clients is debatable 11
TCP well placed to extend goal setting to include participation
Goal setting
Goal setting
Client-centred goal setting
Team approach with an increasing focus on the
client and attainment of goals 13
Increases participation, performance, and
persistence 14
Results in benefits to the interdisciplinary team 15
Client-centred goal setting
Leach et al., identified 3 categories of goal-setting 16
Therapist controlled
Therapist led
Patient focused
Therapists setting impairment and activity goals, whereas
patients set participation goals
Implementing a patient centred goal-setting approach
Goal setting tools
Designated goal facilitation tool significantly
improves goal attainment 17
Goals set should inform development of plans for
further assessment, intervention and discharge
and maximises goal attainment 18
Interdisciplinary teamwork
“…individuals from several disciplines working toward a
common goal”19… “includes not only the professionals but
the patient and his/her family and significant others”20
Identify as a “team”, not as individual team members 21
Respect, value, and solicit contribution from all members
Flexible leadership – task dependent
Provide a forum for problem solving
Work interdependently
Shared decision making
Develop new ways of “seeing”
We believe…
“The only way to find out what
clients want, is to ask them” 22
Maximising goal achievement
Motivational Interviewing (MI)
“A goal directed, client-centred counselling
style for eliciting behaviour change by helping
people explore and resolve ambivalence” 23
Motivational Interviewing is:
Goal directed
Client-centred
Collaborative process
Respects the client’s choice regarding change
Form development & trial
Feedback & review
Negative feedback
“Oh no, not another change!”
“Clients set unrealistic goals”
“Too busy”
“Outside my comfort zone”
Positive feedback
Eliminates unnecessary paperwork
Promotes client-centred practice
Facilitates a goal and client focussed approach to goal review
Demonstrates compliance with accreditation standards
Increased goal attainment
Identified need to increase client motivation
Further improvements
Outcomes
Increased client-centred focus to goal review
Streamlined goal review
Improved communication between clinicians
Prioritizing of interventions
More focused approach to interventions
Future considerations
Acknowledgements
The presenters would like to also acknowledge
and thank the work of the TCP Clinical Review
Portfolio members: Catherine Cummings,
Samantha Goodwin, Andrew Laundy and
Rebecca Lackie who contributed to this project.
References
1. WHO: World Health Organisation, International Classification of Functioning, Disability and Health (ICF).Geneva: World
Health Organisation; 2001.
2. Baum, C.M. (2011). Fulfilling the promise: Supporting participation in daily life. Archives of Physical Medicine and
Rehabilitation, 92, 169-175.
3. Fairhall, N., Sherrington, C., Kurrle, S.E., Lord, S.R., & Cameron, I.D. (2011). ICF Participation restriction is common in frail,
community-dwelling older people: an observational cross-sectional study. Physiotherapy, 97, 26-32.
4. Horowitz, B.P., & Chang, P.F. (2004). Promoting well-being and engagement in life through occupational therapy
lifestyle redesign: a pilot study within adult day programs. Topics in Geriatric Rehabilitation, 20(1), 46-58.
5. Graham, S.K. & Cameron, I.D. (2008). Assessing outcomes in an Australian rehabilitation service: Using an ICF-based
approach. International Journal of Therapy and Rehabilitation, 15(9), 392-399.
6. Wade, D.T. & de Jong, B.A. (2000). Recent advances in rehabilitation. British Medical Journal, 320, 1385-1388.
7. Law, M. (1998). Client-Centered Occupational Therapy. United States of America: Slack Incorporated.
8. Palmadottir, G. (2006). Client-therapist relationships: experiences of occupational therapy clients in rehabilitation.
British Journal of Occupational Therapy, 69(9), 394-401.
9. Maitra, K.K., & Erway, F. (2006). Perception of client-centred practice in occupational therapists and their clients. British
Journal of Occupational Therapy, 69(4), 169-176.
References
10. Law, M. (2013). Basic and Advanced Setting Goals and Evaluation Outcomes Using the Canadian Occupational
Performance Measure (COPM). OT Australia Professional Development Event, Brisbane, Australia.
11. Cott, C.A., Wiles, R., & Devitt, R. (2007). Continuity, transition and participation: Preparing clients for life in the
community post-stroke. Disability and Rehabilitation, 29(20-21), 1566-1574.
12. Liu, K.P.Y., Chan, C.C.H., & Chan, F. (2005). Would discussion on patients’ needs add value to the rehabilitation
process? International Journal of Rehabilitation Research, 28(1), 1-7.
13. Gage, M. (1994). The patient driven interdisciplinary care plan. Journal of Nursing Administration, 24(4), 26-35.
14. Locke, E.A., & Latham, G.P. (2002). Building a practically useful theory of goal setting and task motivation: a 35-year
odyssey. American Psychologist, 57, 705-717.
15. Holliday, R. (2004) Goal-setting: Just how client orientated are we? Therapy Weekly, March 25.
16. Leach, E., Cornwell, P., Fleming, J. & Haines, T. (2010). Patient centred goal-setting in a subacute rehabilitation setting.
Disability and Rehabilitation, 32(2), 159-172.
17. Parsons, J.G.M. & Parsons, M.J.G. (2012). The effect of a designated tool on person-centred goal identification and
service planning among older people receiving homecare in New Zealand. Health and Social Care in the
Community, 20, 653-662.
18. British Columbia Guidelines & Protocols Advisory Committee (2008). Frailty in Older Adults – Early Identification and
Management. Retrieved April 21, 2013, from http://www.bcguidelines.ca/guideline_frailty.html
References
19. Rothberg, J. (1981). The rehabilitation team: Future direction. Archives of Physical Medicine and Rehabilitation, 62,
407-410.
20. Melvin, J.L. (1989). Status report on interdisciplinary medical education. Archives of Physical Medicine and
Rehabilitation, 70, 273-276.
21. Crawford, G.B. & Price, S.D. (2003). Team working: Palliative care as a model of interdisciplinary practice. Medical
Journal of Australia, 179(6), 32-34.
22. Wennberg, J.E. (1990). Outcomes research, cost containment, and the fear of health care rationing. New England
Journal of Medicine, 323(17), 1202-1204.
23. Hettema, J., Steele, J., & Miller, W.R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, 91-
111.