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Working Smart to Achieve Functional Outcomes

In this episode of Kessler Foundation's podcast, Gretchen March, OTR, Kessler Institute for Rehabilitation, presents “Working Smart to Achieve Functional Outcomes Using ICF Framework for Goal-Writing and Treatment Planning.”



This is part four of an eight part series. Listen to the series as it's posted. 

Listen to the podcast, view the transcript and download this episode and others for free on Apple PodcastsSoundCloudPodbeanor where ever you get your podcasts.

Below is an excerpt from the lecture.


So what we're going to talk about now is using the ICF framework. Are people familiar with that? The International Classification of Functioning? Back in the early '2000s, the World Health Organization wanted to kind of stabilize the language around therapy and rehab and goals and things like that so that, wherever you were in the world, we were all able to speak the same language. I don't know how far it's taken off but it's a great idea and a lot of really good concepts. So I want to try and improve understanding of the purposes of goal setting to engage them in their rehab patients, support patient-centered clinical practice and team coordination, look at improving and understanding of the factors that affect development and use of goals in rehab.

If we write really excellent goals, you have a great treatment plan. Your day is so easy. So the time it takes you to really think about real, valid goals is worth it. To increase clinician skills in working collaboratively with their patients to develop patient-centered goals and rehab plans. So the whole kind of concept from these previous lectures has been really involving your patient and making it about them. And to provide clinicians the ability to write, review, and use patient-centered smart rehab goals that support rehab practice using the SMARTAAR goal process which we'll go over that. So this is a great slide because it talks about the traditional versus the enablement approach. Now, enablers are bad, usually. When we say, "Oh, you're an enabler." That's something we don't want to be. Well, in this world, we do because we want to enable our patients to be their own advocate. We want it to be about them and not us. So let's take a look here at the traditional model. There's a patient dependency. So the health professional takes responsibility for the treatment plan.

The Enabling Approach
Don't do this to me today. Okay. So in summary, the enabling approach is an intervention in which the healthcare provider recognizes, promotes, and enhance the patient's ability to control their health in life. And that's what Ariel was just speaking about, right, with relation to exercise? It aims to achieve patient empowerment. The staff acting as enablers or facilitators to get the person up and running and on board and successful. It's increasing teamwork and increasing the use of clinicians skills and experience. So it allows you to do a lot more mentorship with each other in a team, improve continuity of care, and improve communication.

So if you look at this diagram, we have the clinician-driven treatment plan and the patient or goal-driven treatment plan. And typically, in the clinician-driven plan, the treatment plan is developed and we identify the goals. So we do the assessment and we think, "Okay. They're having trouble getting out of bed. They're having trouble getting on the toilet. They're having trouble eating. So these are the things we're going to do. These are the things we're going to practice. These are my goals." After you get that, you identify those goals. But with the patient or goal-driven treatment plan, it goes back to that initial assessment when you're doing your evaluation and you explore with the patient what are your important things to get you home. What are your goals? What do you need to do to be successful at home? And so after that, the clinician will sit back and write a treatment plan based on that. So you see the difference? A lot of us are probably still on the left, right? Because that's what we've always done. So it's one of those situations.

Activity and Participation Example
You want to look at the influences of the activity and participation level activities. There are social and culture things. So your whole identity of who you are if you can't go back to work. What am I going to do? The need to fulfill your social role. So before, you were the primary person bringing all the money in. What's that do to a person if they can't do that after a stroke? The need to meet personal and environmental demands and that's more at the activity level, being able to just have access to things like Ariel was speaking about with the fitness centers. And the need to accommodate personal preferences.

So the relationship between goal setting and participation activity in impairment level goals goes something like this. The patient goal is usually the participation level goal. When you do the interview correctly, what do you need to be able to do? What is it that's most important to you following the stroke, that you feel the loss of, that you want back? However you say it to appeal to them, to get that level but don't just let them say, "I want to walk." Because you can probe a little more like, "How much walking did you do before?" "Oh, I used to walk three miles in the park every day." That's a different person than the person like, "Well, I used to just walk into my kitchen and back and forth." Doesn't mean you're not going to work at it but just saying, "I want to walk," is very basic because they're only thinking about what they can't do right now.

My impairment is I can't walk. So my goal is I want to walk. But what do you want to walk for? Well, I need to walk because I do all the supermarket shopping myself and I'm the one who has to go and the store is very big and this is what I need to do. So when you get that participation level goal, then the next phase is the patient steps and those vary between participation and activity, their impairment goals and the assessment results from your evaluation. But the action plan, the intervention and assessment regarding the impairments and other actions to achieve a step become the action plan.