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Home / Goal-setting Instruments in Geriatric Rehabilitation a Systematic Review Pdf

Goal-setting Instruments in Geriatric Rehabilitation a Systematic Review Pdf

Introduction

Many older adults experience increasing dependence, decreasing social interaction, and a growing number of professionals involved in their care and support [i,2]. Due to these multi-domain consequences, older adults prefer individualized care that supports their unique constellation of bug, which is generally not supported by the current traditional organization of the healthcare arrangement [iii,4]. The aim of person-centred care is to put the person in the middle of the care and to match the person's needs and preferences in a holistic way [5–7]. Therefore, it uses methods that meet a person'south private needs and that enhance a person's involvement in their own intendance. As a consequence, person-centred care aims to amend individual outcomes, support successful crumbling and reduce costs [five].

A common method to meliorate person-centeredness in wellness care is goal planning. Goal-planning promotes a person's health by enhancing self-efficacy [8] and can improve the impact of an intervention [9]. Goal planning in a intendance setting consists of two aspects, goal setting and care planning [9]. Information technology supports communication between the patient and the intendance professional person with the aim to capture a patient's specific values and circumstances as the basis for developing individualized goal plans [10]. In this way, patient autonomy [11] and patient-centered care is enhanced [10,12].

Another important reward of goal planning is that it enables care professionals, patients and researchers to monitor the effects of care and support, and to quantify the impact of interventions [xi]. For this, various goal setting instruments are developed [xiii]. With these instruments, people tin can score the severity of problems, set goals, and measure the caste of goal attainment over time. Common examples of these instruments are Goal Attainment Scaling (GAS) [xiv] and the Canadian Occupational Functioning Measure out (COPM) [fifteen].

With these approaches the outcomes of patients with very heterogeneous symptoms tin be aggregated. However, the statistical analysis and interpretation of GAS endpoints is challenging considering the goals of individual patients may be unique and the number of goals across patients may vary [16]. For the COPM, feasibility was considered limited within out-patient settings and for older developed populations [xiii]. As a issue, current practise and opinions differ substantially about the nigh feasible scoring instrument [thirteen]. Therefore, nosotros developed a goal-planning method using severity scores ranging from 0 to 10, equivalent to the COPM method and to commonly used and feasible pain rating scales [17].

Next to the scoring instrument debate, little evidence exists virtually the feasibility [18] and effects of goal setting with frail older adults [19]. Within this population, very heterogeneous needs and goals tin can exist [20]. Therefore, we decided to utilise the International Classification of Functioning, Disability and Health (ICF) to identify health-related problems, equally this nomenclature covers all domains of human performance [21]. Because the complete classification is too broad for application inside an assessment, we used the Geriatrics, an ICF-based assessment tool, reflecting the most relevant health-related problems in customs-living older adults [22].

We hypothesized that community-living older adults, who participate in a person-centred and integrated health service, are able to address their health-related problems using a goal-planning method with severity scores. Therefore, the aim of the present report is to gain an insight into the results of goal planning using severity scores amongst customs-living older adults participating in Cover, a person-centred care health service for community-living older adults. We offset examined the prevalence of goals ready by older adults. Nosotros then examined goal progress and goal attainment. Finally, we compared the goal attainment results for older adults with dissimilar frailty levels and differences inside ICF clusters to provide possible explanations for why goals were attained or non.

Materials and methods

Design and setting

Nosotros performed a pretest-posttest study with the intervention grouping of a randomized controlled trial which is part of Cover [23]. Embrace (in Dutch: SamenOud) is a person-centred and integrated care and back up service for customs-living adults aged 75 years and older. The ultimate goal of Comprehend is to prolong the ability of older adults to continue living in their own homes. After assessing the written report protocol of the Encompass trial, the Medical Ethical Committee of the University Medical Heart Groningen concluded that ethical approval was non required under the Dutch legislation in medical trials (Reference METc2011.108). The study was conducted in accordance with the Declaration of Helsinki and the Code of Conduct for Wellness Research (2004). More details of the Encompass study have been published previously [23].

Sample

Participants were enrolled in the Embrace study during the offset quarter of 2012. Of the 24 general practitioner practices invited, 15 decided to participate. All persons aged 75 years and older from these practices were invited to participate, of whom 1456 consented (48.7% response rate). After giving informed consent, participants provided demographic and wellness-related data through postal surveys. Participants were classified into iii adventure profiles to ensure a suitable intendance level. These were robust, frail, or complex care needs, according to the participant's self-reported complexity of care needs (INTERMED for the Elderly Self-Assessment (INTERMED-E-SA) [24]) and level of frailty (Groningen Frailty Indicator, GFI [25,26]). The robust hazard profile included older adults without complex care needs (INTERMED-E-SA < 16) and with a relatively low frailty level (GFI < 5). The frail chance contour comprised older adults with a higher level of frailty who were at take chances of developing complex care needs (INTERMED-East-SA < sixteen and a GFI ≥ 5), while the complex care needs risk contour included older adults with intendance needs in multiple domains (INTERMED-East-SA ≥ 16, regardless of GFI score). These 1456 participating older adults were stratified into the three risk profiles. Subsequently they were randomized to the intervention or control grouping with balanced allocation on demographic and clinical characteristics. In total 747 older adults were randomized to Embrace intervention groups within the risk profiles: robust (n = 438), frail (n = 122), and circuitous care needs (n = 187).

Older adults with the robust profile were in good health, simply at risk for the consequences of aging and therefore invited to participate in the "preventive and proactive self-direction support programme" with customs group meetings that supported them to stay healthy as long as possible. They did not receive individual support from a case director. Consequently, they adult no goal program(s) and were therefore not eligible for inclusion in this study.

Older adults with the frail hazard profile and those with complex intendance needs were eligible for inclusion in the current study because these older adults received private support from a case director and formulated goal plans. Included were older adults with at least ane goal program.

Embrace

Each full general practice participating in Embrace set up a multidisciplinary Elderly Care Team comprising a general practitioner, an elderly intendance physician and 2 case managers. Elderly care physicians are doctors trained in, and consulted for, issues in the complex geriatric care pathway [27,28]. The case managers were a social worker (for older adults with the delicate take chances profile) or a district nurse (for older adults with the complex care needs chance profile). Instance managers were trained to give individual support in collaborative goal setting with shared conclusion-making, amidst other skills. Frail older adults were visited in one case a month and older adults with complex care needs fortnightly by their example manager to develop, monitor, navigate, and evaluate their goal plans. 1 of the aims of the goal plans was to encourage the older developed to carry out activities by themselves or, if necessary, with help from a caregiver or professional. During the monthly meetings of the Elderly Care Team, the goal plans of the older adults were discussed when deemed necessary.

Goal-planning procedure

The goal-planning procedure in the Embrace intervention grouping consisted of three steps: (one) geriatric assessment, (2) goal-programme development, and (3) goal-programme evaluation. In Figure 1, each of these steps is shown and illustrated with an case.

Figure 1. Overview of the goal-planning process inside Cover, with two goal plan examples. Elderliness = Geriatric ICF Core Set, or non to the editor'southward taste. Baseline score: The severity of a problem identified during the assessment. Target score: The score the older adult intended to attain past performing the planned activities to accost the specific problem. Finish score: The severity of the health-related problem later on at evaluation. Baseline score, target score, and stop score are severity scores and range from 0 to 10 with higher scores indicating more than severity. Feasibility score: The likeliness of a goal to exist attained was rated to make older developed expectations explicit, discussed and adjusted accordingly. Score ranges from 0 (totally unlikely) to 10 (certainly viable). Black: older adult in charge; Grey: older adult and the instance manager mutually in charge; light grey: initiated by the example director. In italic: instance of care and goal plan.

  1. During the first consultation, a comprehensive geriatric assessment was carried out by the case director to identify health-related issues experienced by the older adult. The Geriatric ICF Core Set (Geriatrics) was used [22] to guide this assessment. Information technology consists of 29 categories from the ICF [21], covering the four ICF-components: Body Functions, Body Structures, Activities and Participation, and Environmental Factors. Consensus on the content of the Cadre Set was attained during a Delphi written report by an expert console with older adults and medical and not-medical health professionals. The Core Ready was validated in clinical practice with participants of the Embrace studies [22]. The items in the Geriatrics reflect the most relevant health-related problems amid community-living older adults without dementia.

    The severity of issues identified during the assessment was rated past the older adults using a severity score. Scores could range from 0 to 10, with lower scores indicating a less astringent problem. After a feasibility pilot, a ruler was added to support the older adults to determine the severity score of their health-related problem. This ruler was a 20 cm calibration with images of faces (from happy to sad), adapted from the faces hurting scale which is known to improve understanding of visual analogue scaling scores [29].

    In case of possible cerebral limitations a relevant intendance giver (most of the time a spouse) participated in the assessments or visits of the case manager with the older adult.

  2. Later, the older adult selected from the assessment all health-related bug that he or she aimed to meliorate. Next, the older adult formulated a goal for each of the selected problems using collaborative goal setting with the case manager, and set a target score. This target score resembled the score the older developed intended to achieve by performing the planned activities to accost the specific problem. To reach this goal, appropriate and feasible activities that were assumed to lead to the attainment of the goal were discussed and selected by the case manager and the older adult. These activities together with the wellness-related trouble and the scores were considered the "goal plan." Finally, the feasibility of the goal plan was assessed. The older adult was asked by the case manager to provide a feasibility score per goal, with scoring options ranging from totally unlikely (score 0) to certainly feasible (score 10). The case managers were instructed to support the older adult to revise the target score or the selected activities if feasibility was insufficient (rated below six) – in other words, with a low feasibility score, the goal seemed too hard to reach. To improve feasibility, either the target score was lowered or the selected actions were adapted to amend feasibility. In this way, expectations of older adults were made explicit, discussed, and adjusted accordingly.

  3. Each goal program was evaluated with the older adult within a predetermined time-frame or at the very to the lowest degree earlier the cease of the 12-month intervention period. The severity of the health-related trouble at that given time is the end score. The older adult rated this end score using the faces scale.

Each goal plan thus ultimately concerned a health-related problem with four scores (three severity scores (baseline score, end score, and target score) and a feasibility score) and activities and interventions required to obtain the target score. All goal plans were registered in an electronic customer registry organisation.

Measurement instruments

At baseline, before the cess with the case managing director, older adults provided health-related information with validated self-assessment questionnaires.

Frailty was assessed using the Groningen Frailty Indicator (GFI). It comprises 15 items, divided over four domains: physical, social, cerebral, and psychological. The total score can range from 0 to 15, a higher score indicating a higher level of frailty [26].

Care complexity was measured with the INTERMED for the Elderly Self-Cess (IM-E-SA). It comprises 20 items, divided over four domains: biological, psychological needs, social needs, and healthcare, approached from 3 different time perspectives: history, current state, and prognosis. The total score can range from 0 to 60, a higher score reflecting a higher level of complexity [24].

Activities of daily living (ADL) were measured by the modified Katz ADL index. It comprises xv items and measures 8 concrete and vii instrumental ADL. The total score tin range from 0 to xv, a college score indicating worse functional status [30].

Health condition was measured by the EQ-5D-3L [31]. It comprises five items, divided over 5 dimensions of health: mobility, self-care, usual activities, pain/discomfort, and feet/depression. Scoring options ranged from "no bug" to "severe bug" on a three-point scale. Every score was aggregated to one score with the Dutch value set created past time-trade off principle [32]. Possible scores in this value set up tin can range between −0.33 and i, with one indicating the best health status.

Assay

Health-related issues were classified into the almost suitable ICF category past the case managers using the ICF categories in the GeriatrICS or by using the ICF browser (http://apps.who.int/classifications/icfbrowser/). 2 researchers (W.R., R.B.) independently checked the classification of the health-related problems into the ICF categories using the descriptions of the perceived issues given past the case managers and following the ICF linking rules [33]. In case of disagreement between the researchers, a third researcher (K.West.) was consulted. When a health-related trouble could non be classified by the case manager, 2 researchers (W.R., K.W.) independently classified the trouble into the almost suitable ICF category following the ICF linking rules [33]. If there was no immediate agreement between both researchers, consensus was reached by discussion. Subsequently, to proceeds an insight into the domains of health-related problems, the ICF categories were grouped into 1 of the half-dozen corresponding clusters: Mental Wellness, Concrete Wellness, Mobility, Personal Care, Nutrition, or Support [34].

A goal programme was included in the assay when information technology was consummate, meaning that there was a description of the health-related problem, a baseline score, a target score besides as an stop score available. By calculating the difference between the target score and the end score, nosotros adamant the extent to which the goal was attained. Goal plans with end scores equal to or lower than target scores (differences ≤ nix) indicated goal attainment. The proportion (with 95% confidence intervals (CI)) of goals attained for the total sample for each risk profile and for each ICF cluster was calculated. Goal progress was calculated by subtracting the baseline score from the finish score. Differences ≤ null indicated goal progress.

The baseline characteristics of the older adults were described for each risk contour and divergence were tested between risk profiles. Baseline differences were also assessed between the included older adults (i.e., older adults with at least i evaluated goal plan) compared to all older adults with at least one formulated goal plan. Nominal baseline characteristics were assessed with chi-foursquare test using continuity correction. Differences in linear and ordinal baseline characteristics, target scores, and proportions of goals attained between the adventure profiles were assessed with Mann-Whitney U test. Not-parametric statistical tests were used in calorie-free of the discrete level of data obtained with the severity scores. The significance level was prepare at 0.05. Statistical analyses were conducted using SPSS 23 (Released 2015. IBM SPSS Statistics for Windows. Armonk, NY: IBMCorp.)

Results

Information available for analysis

Of the 747 older adults in the intervention group, 309 older adults were delicate or had complex care needs, and were therefore eligible for inclusion (Figure 2). In full, 288 of these older adults had at least one goal plan. Of these 288 older adults, n = 55 did not evaluate whatsoever of their goal plans. Of the total 920 goal plans, 84 goal plans were not evaluated within the evaluation flow of 12 months. Goal plans were by and large not evaluated due to loss to follow-up of the older adult, for example, due to admission to a nursing dwelling or conversion to the robust profile (in which they received no case direction nor follow-up assessments anymore). In add-on, goals were sometimes not evaluated considering the older adult was not able to rate the severity scores (n = ii and 8 goal plans), not able to assign a goal (n = 4 and 12 goal plans) or had likewise severe cerebral impairments (2 goal plans). Therefore, 233 older adults were included in the written report and 836 goal plans were included in the analysis.

Effigy 2. Flowchart of inclusion of eligible older adults (n), separated for the complex intendance needs and frail adventure profiles, and their goal plans (chiliad). *Proportion of older adults (and goal plans) included in analysis of the sample eligible for goal plan evolution. NH: nursing home; north: number of older adults; m: number of goal plans; inside grey box: older adults from command grouping and robust care profile: they did non receive individual support from a case managing director and therefore formulated no goals plan.

Baseline characteristics of participants

The baseline characteristics of the 233 participants are shown in Table i. The mean age of participants was 81.5 years, i-third was male and half was married. The most common educational level was (uncompleted) primary school or depression-level vocational grooming. Older adults with the complex care needs run a risk profile had – as a result of the stratification – more chronic conditions, used more medications, had more (I)ADL constraints and a lower health-related quality of life compared to older adults with the frail take chances profile. All these differences between the strata were statistically significant (p ≤ 0.001).

Table 1. Baseline characteristics for the total older adult sample and for each hazard contour.

Prevalence and classification of goal plans

The median number of goal plans for each older developed was 3 (IQR 2-v). At that place was no meaning departure in the median number of goal plans betwixt older adults with the complex intendance needs profile (median 3 IQR ii-five) and older adults with the frail contour (median 3 IQR 1–four, p values 0.06).

Three quarters of all goal plans could exist classified using the ICF categories from the Elderliness and were grouped into one of the 6 predefined clusters. Three highly prevalent health-related problems were non captured in the GeriatrICS and therefore non part of whatsoever predefined cluster. These health-related problems could exist classified using the ICF and were clustered into the ICF categories pain (25% of all older adults), looking after one'south health (7%), and recreation and leisure (7%). Most older adults formulated goal plans within the physical health (64% of all older adults), mobility (50%), or back up (49%) clusters, while problems in the personal care cluster had the everyman prevalence (3%). Figure 3 shows the prevalence of goal plans of each cluster or (new) ICF category among the total sample and for each risk contour. The prevalence of each ICF category within the clusters is shown in Supplementary Table S1.

Figure 3. Prevalence of goal plans (north = 836) amongst older adults (north = 233) and for each risk profile, categorized into 6 predefined clusters and 3 other highly prevalent ICF-categories. Night gray: full sample; black: circuitous care needs; low-cal greyness: delicate.

Results of goal planning for the total sample

Table ii presents the goal-planning results for the full sample and for each take a chance profile. The mean baseline score for the health-related issues in the total sample was half-dozen.0 (SD two.0), while the mean target score was three.3 (SD 2.0). In total, 619 of the 836 goals (74%, CI 71–77) were attained. Of all the older adults, 89% (CI 84–92) were able to achieve at to the lowest degree one goal. The terminate scores were, on average, 0.2 points college than the target score (SD 1.ix). The hateful goal progress (departure betwixt end score and baseline score) was ii.5 (SD 2.3).

Table 2. Goal-planning results.

The median length of a goal time-frame was 283 days. Seventy-seven per cent of goal plans were closed during the intervention year (in contrast to at the finish of the intervention yr). There was no difference in proportion of goal attainment betwixt the goals closed during the intervention year compared to the goals airtight at the end of the intervention year.

Differences betwixt the risk profiles and goal clusters

The mean baseline scores at the start of the intervention were similar for both risk profiles (see Table ii). However, older adults with the circuitous care needs profile had lower target scores, meaning that a larger improvement was intended, compared to the frail older adults (p < 0.001). Even so, the same proportions of goals attained (74%) were establish in both risk profiles.

When comparing the results for the ICF clusters and ICF categories, the well-nigh severe health-related problem was pain (hateful baseline score 6.7, SD i.7), followed by mobility, mental health, and personal care. Lowest severity at the showtime was rated for recreation and leisure (4.viii SD 2.ii). The highest proportions of goals were attained within the clusters of personal intendance and physical health (resp. 88% CI 53–98 and 78% CI 72–83), while the lowest proportions of goals were attained within the mobility cluster and the hurting category (resp. 69%, CI 62–76 and 68%, CI 56–78). Supplementary Table S1 shows a description of the results of the goal-planning process for each ICF-category inside the GeriatrICS.

Word

The aim of this study was to gain an insight into the results of goal planning using severity scores in a person-centred intendance setting for customs-living older adults. Nosotros plant that older adults who were frail or had complex care needs and participated in a person-centred and integrated health service were able to attain well-nigh 3 quarters of these goals, while the mean differences between target scores and end scores were trivial. Goal progress was at mean 2.5 points, which is ordinarily seen as an clinical of import change on a 0–10 calibration [35].

Most older adults formulated goal plans within the physical wellness, mobility, or support clusters, and the least within the self-care cluster. The high prevalence of goal in the first three clusters is not uncommon in the literature. For instance, older adults who formulated life-goals mainly preferred maintenance of health, increased concrete activity, and increased socialization [36]. Health is thus an important goal, fifty-fifty when seen in a broader life-goal perspective. Indeed, in the report of Waldersen et al. [37] amid customs-living older adults receiving occupational therapy at domicile, goals were mainly focused on mobility and the least on self-care. Similar to our results, in this study information technology was found that 72% of goals were attained.

Goals in the physical cluster were the nearly likely to be attained and goals in the pain and mobility clusters seemed the about hard to attain. Again, Waldersen et al. likewise found that goals related to mobility (walking) and pain (within body functions) had the lowest attainability [37]. There is lilliputian prove explaining the deviation in goal attainability across clusters. The relatively expert attainability of goals in the physical cluster is perchance due to the central part of the full general practitioner in the Elderly Intendance Teams in this study. Equally they feel most able to solve problems in the physical domain compared to other domains [38]. Another explanation might be the persistent or stubborn character of pain [39–41] and psychological complaints [42] in contrast to physical complaints.

An important finding was that hurting, although it was a prevalent (29%) and the almost severe health-related problem, was non included in the Elderliness. Information technology is known that pain is an important health-related problem amidst older adults [40,43,44] and it is more often overlooked within geriatric assessments [45]. In a thorough meta-assay of qualitative literature, the "accommodation of older adults to the inevitable" and "the reluctance to pain medication" seems a barrier to report pain. This may exist an explanation for why it was not included in the GeriatrICS subsequently a Delphi procedure with expert panels of older adults and intendance professionals.

Methodological considerations

Of import strengths of this study are the large sample of participating older adults and the large number of goal plans included in the assay. By using the Geriatrics, that is, based on ICF nomenclature, nosotros covered the broad telescopic of performance and disabilities experienced by the private participants [21]. By classification of the health-related bug in ICF clusters we created a commencement of a categorization of health-related goals for older adults [46].

Our goal setting method using severity scores considers many aspects of goal attainment, every bit proposed by Krasny-Pacini et al. [47]. The most important aspect we covered was the primal role of the client in prioritizing, judging the relevance, and evaluating goals. This is very important when the aim is to develop person-centred care. Other proposed aspects nosotros applied were training the instance managers in goal setting, classification of health-related problems using ICF categories, providing a goal example in this paper and bookkeeping for feasibility [47].

However, there were aspects which are considered important for the quality of goals and goal setting nosotros were not able to investigate. For instance, fourth dimension-specificity and measurability were not studied. Uni-dimensionality, meaning that a goal is solely about aiming to amend one aspect of a problem, is considered very important for fair evaluation of goals [xvi]. This was, still, hard to achieve. Despite the fact that instance managers were trained to avoid formulating multi-dimensional goals, not each goal plan was uni-dimensionally formulated.

Lastly, examiner bias could have been introduced, for the older adult rated the severity scores twice themselves. Still, we tried to minimize this by asking the older developed to rate the stop score using the ruler without reminding them at their baseline score. Keeping the person-centred aim in mind, this was the best way to capture true person reported and relevant outcomes [48,49].

Commonly used goal setting instruments all take their feasibility bug [13]. By introducing severity scoring from 0 to 10, we aimed for a clinometric measurement instrument which focuses on older adults' preferences to capture relevant outcomes [fifty]. The methodology is known for its easy adoption, besides for people with cognitive impairments [13,17]. Nonetheless, case managers of Comprehend indicated that older adults had difficulty judging the severity of their problems [51]. We are not enlightened of studies comparing different goal setting instruments for older adults. It is therefore interesting to written report the difference in feasibility of our scoring method with other instruments.

We were not able to compare our results on the extent in which older adults in the intervention group attained their individual goals compared to the control group from the RCT of Cover that received care as usual without assessments and goal planning. This might be seen as a potential limitation, equally we were not able to account for the possibility of response shift, which is acquired by the adaptive strategy that allows someone to feel good about their actual health status despite chronic illnesses [52–54]. However, studies concerning goal setting ordinarily lack control groups [55] or experience methodological issues [56]. Because goal setting is suggested to exist constructive in itself [57] it is hard to create control groups with goal plans. Current literature lacks high quality evidence on the effects of goal setting for older adults on quality of life.

Another potential limitation is the exclusion of older adults with non-evaluated goal plans, which might mean that goal attainability was overestimated. However, the risk of selection bias seems minimized, equally the older adults who were excluded subsequently the goal setting procedure, did not differ from those who were included (concerning the variables in Table ane). Furthermore, the relatively low number of excluded goal plans was too small-scale to have bear on on the study results.

Futurity research and clinical implications

Futurity research should examine the effect of goal planning in person-centred intendance on quality of life, healthcare consumption, and costs. In this manner, the added value of goal planning to person-centred care can be substantiated. Next to demonstrating this pragmatic value of goal setting, further work is required to explicate the theoretical goal setting mechanism [58,59].

An important implication for clinical practice and futurity research results from the heterogeneity of the goal plans. This non only indicates that the range of issues experienced past older adults is broad, but also reinforces the importance of a broadly skilled instance managing director. To increment the rate of goal attainment it is advised to get an insight into the deployed interventions and raise the bear witness–base of these interventions.

Conclusions

Older adults are able to formulate and attain wellness-related goals in a person-centred care setting by collaborative goal planning with their instance manager. We therefore recommend that futurity person-centred and integrated intendance programmes for older adults contain goal-planning methods with severity scores to support person-centred care.

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Source: https://www.tandfonline.com/doi/full/10.1080/09638288.2019.1672813