Client Workbook - Hammond

Setting goals and evaluating meaningful outcomes for people living with dementia who are participating in reablement programsClient Workbook

This is an individualised client workbook designed to be used ‘in the field’ to guide the process of goal setting and evaluation for a client who is engaged in a reablement program.

© 2021 the authors. You may copy, distribute, display, download or otherwise freely deal with this work for any purpose, provided that you attribute the authors as the owner. However, you must obtain permission if you wish to (a) include the work in advertising or a product sale, or (b) modify the work.

Suggested citation: O’Connor CMC, Poulos CJ. Setting goals and evaluating meaningful outcomes for people living with dementia who are participating in reablement programs: client workbook. Sydney: HammondCare, 2021.

Cover and internal design – SD Creative

Funding and acknowledgements

This project was proudly supported by the AAG Research Trust. The work was underpinned by focus groups with people living with dementia, their family supporters, and allied health practitioners. The authors would like to thank these individuals for their important contributions; this has been a vital element to development of this guide, ensuring its relevance. We would also like to thank Dr Allison Rowlands for her assistance with the project.

References

For the full reference list associated with this Client WorkBook, please refer to the Practitioner Guide: O’Connor CMC, Poulos CJ. Setting goals and evaluating meaningful outcomes for people living with dementia who are participating in reablement programs: practitioner guide. Sydney: HammondCare, 2021.

3 Evaluating reablement programs for people with dementia – Client Workbook

Client name:

Practitioner name:

Reablement program:

Program start date:

Program end date:


Setting goals and evaluating meaningful outcomes for people living with dementia who are participating in reablement programs

This guide presents a practical dementia-specific model of using Goal Attainment Scaling (GAS) to measure meaningful outcomes from reablement programs.

The model involves using a novel, combined, stepped approach to assessment, through:

1. Choosing therapy goals with clients using newly developed Reablement Goal Lists;

2. Defining these goals using a new dementia-specific adaptation of the SMART(specific, measurable, achievable, relevant and time-bound) Framework; and

3. Scoring using the Gas-Light adaptation of Goal Attainment Scaling to record andevaluate program outcomes.


This guide includes the novel amalgamation of the following three concepts into a single framework to guide the use of GAS to evaluate meaningful outcomes for people living with dementia who are participating in reablement programs:

Process of assessing meaningful outcomes for people with dementia engaged in a reablement program

1. Choose – From the Reablement Goal ListsIdentify personally meaningful and desired goal(s) in partnership with the client

2. Define – SMART Goals using the FrameworkDefine identified goal(s) as Specific, Measureable, Achievable, Relevant, and Time-bound (SMART)

3. Score – using GAS-Lighta) Prior to beginning the reablement program, rate

the client’s current level of functioning towardstheir SMART goal

b) At the end of the program (or another pre-specifiedtime), rate the client’s level of attainment towardsthat goal

Go

al setting and

evaluation

•C

hoo

se go

al(s)

•D

efine ‘S

MA

RT

’ly

•S

core using

GA

S-Lig

ht

Fu

nctio

nal a

bility

Ab

ilities to:

•M

eet own b

asic needs

•M

ove around

•Learn, g

row and

make d

ecisions

•B

uild and

maintain

relationship

s

•C

ontrib

ute

Enviro

nm

en

tH

om

e, com

munity,

bro

ader so

ciety

Enviro

nm

en

tal fa

cto

rs•

Built enviro

nment

•E

quip

ment/techno

log

y

•S

ocial sup

po

rt eg. fam

ily carer

•F

unding

availability

and access

•S

ervice availability and

access

•A

ttitudes to

reablem

entin d

ementia

Reab

lement

•O

ccupatio

nal therapy

•F

alls preventio

n/exercise

•C

og

nitive/com

municatio

n pro

gram

Dise

ase

e.g

. dem

en

tia•

Dem

entia stage

•D

ementia sym

pto

ms

•C

om

orb

idities, injury, p

ain

Perso

nal fa

cto

rs

•A

ge, sex

•E

ducatio

n•

Perso

nality•

Past exp

eriences

Intrin

sic c

ap

acity

Mental and

physical

capacities e.g

.:

•F

unctional co

gnitio

n,m

emo

ry•

Physical ab

ility•

Co

mm

unication ab

ility•

Senso

ry capacities

(e.g. see, hear)

•M

ental health

Reab

lem

en

t in d

em

en

tia is a

bo

ut su

pp

ortin

g fu

nctio

nal a

bility

to m

ain

tain

wellb

ein

g. T

his fig

ure

pro

vid

es a

n o

verv

iew

of th

e d

ete

rmin

an

t fa

cto

rs that m

ake

up

fun

ctio

nal a

bility

(ICF

activ

ity &

partic

ipatio

n): a

n in

div

idu

al’s in

trinsic

cap

acity

(ICF

bo

dy fu

nctio

ns &

structu

re) a

nd

th

eir e

nviro

nm

en

t (ICF

co

nte

xtu

al). P

ractitio

ners sh

ou

ld c

on

sider e

ach

po

ten

tially

co

ntrib

uto

ry fa

cto

r to a

perso

n’s fu

nctio

nal a

bility, in

clu

din

g

any d

isease

(ICF

health

co

nd

ition

) or p

erso

nal fa

cto

rs (ICF

co

nte

xtu

al) a

nd

these

sho

uld

be a

dd

resse

d w

hen

settin

g g

oals a

nd

pla

nn

ing

the

reab

lem

en

t inte

rven

tion

.

WH

O, 20

02, 20

15

6E

valu

atin

g re

ab

lem

en

t pro

gra

ms fo

r peo

ple

with

dem

en

tia – C

lient Wo

rkbo

ok

Fig

ure

1: Facto

rs to b

e co

nsid

ere

d in

esta

blish

ing

realistic

go

als a

nd

desig

nin

g h

olistic

re

ab

lem

en

t pro

gra

ms u

sing

an

ICF

fram

ew

ork


Cho

ose

– fr

om

th

e R

eab

lem

en

t G

oal L

ists

1. Choose – from the ReablementGoal Lists

Identifying personally meaningful and desired goal(s) in partnership with your client

Use the Reablement Goal Lists below (Programs 1-3) to guide a discussion with your client to identify personally meaningful and desired goals. Through this process, the person (and/or their family) should be prompted to consider a range of potential goals that they may identify as personally meaningful/important. Practitioners should consider applying the tenets of supported decision making to support clients in identifying their goals (see page 7 of the Practitioner Guide).7

Figure 1 presents an ICF-mapped holistic overview of the range of factors to be considered for every client to ensure realistic goals are established. For example, a person’s goal might be to regain their ability to manage the garden. This will depend on their personal characteristics or ‘intrinsic capacity’ (e.g. physical and cognitive health and what is possible to achieve through therapy), as well as what social support they have and the environmental context of their backyard garden.10

Practitioners have highlighted the importance of goals from reablement programs to be functional i.e. relate to something that contributes to the individual’s meaningful participation and engagement in everyday life. Once goal priorities have been identified, where possible, client goals should be developed into overall functional goals that allied health teams may work collaboratively to achieve (see case examples pages 15-17 of the Practitioner Guide).

Reablement Goal Lists are arranged by reablement program:

Program 1: Occupational therapy for everyday living

Outlines potential goals that might be identified for an occupational therapy program to support functioning in everyday living activities. The limitations addressed by these programs will be primarily cognitive based and/or secondary to symptoms of dementia.

Program 2: Falls prevention/reduction

Outlines potential goals that might be identified for a falls prevention program or a program aimed at reducing falls or reducing risk for falls.

Program 3: Mobility and physical function

Outlines potential goals that might be identified for an exercise-based program to support mobility and physical functioning in general or towards functional outcomes. The limitations addressed by these programs will be primarily physically based but may also be attributed to dementia.

Use the relevant List(s) to guide a discussion with your client. Circle identified goals.

Pro

gra

m 1: R

eab

lem

ent G

oal L

ist – Occ

up

atio

nal th

era

py fo

r eve

ryd

ay liv

ing

(circ

le id

en

tified

go

als)

8E

valu

atin

g re

ab

lem

en

t pro

gra

ms fo

r peo

ple

with

dem

en

tia – C

lient Wo

rkbo

ok

Leisu

re

•C

om

munity and

social life e.g

.

•R

ecreation and

leisure e.g. p

laying an

instrument, d

ancing, sing

ing, p

laying sp

ort

•C

om

munity life e.g

. outing

s,visiting

the café

•M

aintaining relatio

nships e.g

.

•S

ocial e.g

. socialising

, meeting

with friend

s

•F

amily e.g

. ‘visiting’ g

randchild

ren usingthe iP

ad

Th

inkin

g, p

lan

nin

g, a

nd

cop

ing

•T

hinking ab

out and

planning

activities e.g.

•O

rganising

activities e.g. p

lan andrem

emb

er to attend

an app

ointm

ent,p

lan the shop

ping

•U

ndertake a task e.g

. making

a cup o

f tea

•C

op

ing e.g

.

•M

anage fatig

ue e.g. m

anage

own activity level

•R

educe carer frustratio

n e.g. strateg

ies toco

pe w

ith stress or p

ressure associated

with caring

role

Every

day a

ctiv

ities

•A

ctivities at hom

e e.g.

•P

reparing

meals

•D

oing

housew

ork

•Taking

care of p

lants

•M

ob

ility e.g.

•Lifting

and carrying

ob

jects e.g. laund

ry,sho

pp

ing, vacuum

•F

ine hand use e.g

. writing

, making

a cup o

f tea

•H

and and

arm use e.g

. making

the bed

,g

ardening

•Ind

oo

r mo

bility in the ho

me e.g

. in the kitchento

make a m

eal, in the bathro

om

•O

utdo

or m

ob

ility e.g. in the g

arden, in the

com

munity to

do

the shop

ping

•U

sing transp

ortatio

n e.g. catching

a bus, train

•D

riving

•S

elf-care activities e.g.

•W

ashing self e.g

. showering

, bathing

•C

aring fo

r bo

dy e.g

. do

ing hair, shaving

•D

ressing e.g

. manag

ing b

uttons,

putting

on sho

es

•Transferring

yourself e.g

. on/o

ff the to

ilet

Choose – from the Reablement Goal Lists

Pro

gra

m 2

: Reab

lem

en

t Go

al L

ist – Falls p

reven

tion

/red

uctio

n (c

ircle

iden

tified

go

als)

9E

valu

atin

g re

ab

lem

en

t pro

gra

ms fo

r peo

ple

with

dem

en

tia – C

lient Wo

rkbo

ok

Perso

n w

ith d

em

en

tia-fo

cu

sed

go

als

•S

trengthening

•B

alance, stability

•A

bility to

walk

•A

bility to

use equip

ment to

move aro

unde.g

. walking

frame

•C

hanging

bo

dy p

ositio

n e.g. unp

acking the

dishw

asher

•M

aintaining a b

od

y po

sition e.g

. standing

at theb

athroo

m sink to

brush teeth

•A

bility to

transfer yourself e.g

. into the car, in/o

uto

f the shower, o

n/off

toilet

•C

onfi

dence e.g

. to w

alk outd

oo

rs

•N

utrition

Care

r-focu

sed

go

als

•A

ssisting yo

ur family m

emb

er/friend w

ithd

ementia

•C

om

municating

effectively w

ith your fam

ilym

emb

er/friend w

ith dem

entia

•E

ducatio

n on sup

po

rt strategies and

usingtechno

log

y and aid

s

Enviro

nm

en

t

•D

esign, m

od

ificatio

n, equip

ment

•S

creening fo

r falls risk

•R

isk reductio

n


Pro

gra

m 3

: Reab

lem

en

t Go

al L

ist – Mo

bility

an

d p

hysic

al fu

nctio

n (c

ircle

iden

tified

go

als)

10E

valu

atin

g re

ab

lem

en

t pro

gra

ms fo

r peo

ple

with

dem

en

tia – C

lient Wo

rkbo

ok

Activ

ity o

r task

focu

sed

go

als

•Ind

oo

r mo

bility in the ho

me

•O

utdo

or m

ob

ility in the gard

en and co

mm

unity

•P

ush things/p

ick things up

, carrying o

bjects

e.g. carrying

shop

ping

, putting

washing

away

•A

bility to

do

daily activities e.g

. shop

ping

,co

oking

, laundry, cleaning

•M

anaging

self-care needs e.g

. showering

, dressing

•U

sing yo

ur hands e.g

. knitting, o

pening

ap

acket, writing

•H

and and

arm use e.g

. op

ening a jar, b

rushing hair,

hanging

washing

out

Oth

er

•M

anaging

diet and

nutrition

•P

ain manag

ement

•A

rthritis manag

ement

Physic

ally

focu

sed

go

als

•S

trengthening

(legs, arm

s, hands)

•B

alance

•M

aintaining o

r develo

ping

fitness

•R

ange o

f mo

tion/fl

exibility

•A

bility to

walk

•C

hanging

bo

dy p

ositio

n e.g. turning

over in bed

•M

aintaining a b

od

y po

sition e.g

. standing

inthe kitchen to

wash the d

ishes

•A

bility to

transfer yourself e.g

. into the car,

in/out o

f the shower, o

n/off

toilet



Defi

ne –

SM

AR

T g

oals

usi

ng

th

e d

em

en

tia-s

pecif

ic F

ram

ew

ork

Define identified goal(s) as Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART).

Once the goal has been identified in partnership with the client, the practitioner needs to define it as a SMART goal (see Table 1). The SMART Framework outlined in Figure 2 provides practitioners with a range of examples to help in defining the goal explicitly using two broad domains:

1. Support needed: practitioners shouldfirst consider the level of support neededin completing the goal activity i.e. howmuch assistance is needed from anotherperson and is any equipment or changeto the environment required;

2. Quantifiers: the quantifiers around theclient’s participation in the goal activityshould then be defined. How willattainment of the goal be measuredi.e. what percentage of engagement/participation is expected, or what willthe unit of measurement be?

The examples outlined in the Framework provide a set of variables and levels of attainment that may assist in setting comprehensive SMART goals and consistently quantifying varying attainment levels. This is not an exhaustive list and should be used as a ‘prompt sheet’ to help practitioners with rapidly considering a range of options that may apply to reablement program goals for their clients with dementia.

2. Define - SMART goals usingthe dementia-specific Framework


Defi

ne –

SM

AR

T g

oals

usi

ng

th

e d

em

en

tia-s

pecif

ic F

ram

ew

ork

Table 1: SMART goal features

Specific The goal needs to be defined as explicitly and clearly as possible.

• What – what goal does the client hope to achieve?e.g. walk to their mailbox to check the mail daily, continue meetingtheir friend for coffee at the café every Tuesday

• Who – who will be involved in attaining this goal?e.g. will the person’s family member or carer play an importantrole in working towards this goal?

• How – how will this goal be attained?e.g. engaging in a falls prevention program, learning to use newequipment or strategies to compensate for a limitation secondaryto their dementia

• Where – where will the goal be attained or the program beconducted?

Measurable How will the outcome be measured? e.g. level of assistance required to complete an activity, distance walked to reach the shops, length of time able to stand to do the washing up

Attainable In the context of the person’s intrinsic capacity and their environment (refer to Figure 1), is the identified goal attainable?

Relevant Step 1 of this process is about supporting the client to identify meaningful goals that they wish to achieve

Time-bound What is a realistic timeframe for this goal to be attained? e.g. at the end of the reablement program, within 4 weeks

(Bovend’Eerdt et al. 2009; Bowman et al. 2015, Schut et al. 1994)

Exam

ples o

f supp

ort need

ed

Peo

ple

Eq

uip

men

tE

nviro

nm

en

t

ASSISTA

NC

E

Co

mp

lete

ly d

ep

en

den

t

2-p

erso

n a

ssist

1-perso

n a

ssist

Sta

nd

-by a

ssistan

ce

Pro

mp

ting

Su

perv

ision

Ind

ep

en

den

t

INITIA

TION

Activity set up

and p

hysical pro

mp

ting

Activity set up

and verb

al pro

mp

ting

Activity set up

and visual p

rom

pt

(e.g. w

hite bo

ard)

Verb

al pro

mp

ting, sets up

own activity

Visual p

rom

pt, sets up

own activity

Manag

es own p

rom

pting

system e.g

. diary

Initiates indep

endently

CO

MM

UN

ICA

TION

Sing

le wo

rd instructio

ns and p

hysical cueing

Sing

le wo

rd instructio

ns and visual cueing

Sing

le wo

rd instructio

ns

Use o

f com

municatio

n technolo

gy e.g

. iPad

Red

uced item

choice w

hen asked q

uestions

(e.g. 2 o

r 3)

Time need

ed to

pro

cess questio

ns and

respo

nd

MO

BILITY/TR

AN

SFER

S

Ho

ist/lifter, wheelchair, slid

e b

oard

, walking

frame, w

alking stick

CO

MP

LEX

AD

Ls

Raised

gard

en bed

Timer

BA

SIC A

DLs

Show

er chair, over toilet aid

, lo

ng hand

led reacher,

adap

ted item

s

CO

GN

ITION

/QO

L

Diary/calend

ar, white

bo

ard/o

rientation, tim

er, iPad

(e.g

. Zo

om

, Skyp

e)

FALLS P

RE

VE

NTIO

N

Mo

nitors/alarm

s, shower

chair, over toilet aid

, walking

fram

e, walking

stick, hom

e m

od

ificatio

ns e.g. ram

p, rails

PH

YSIC

AL

Red

uce distractio

n (visual, no

ise)

Enhance lig

hting

AC

TIVITY

Red

uce activity materials

Red

uce activity steps

Mo

dify activity

SOC

IAL

Limit num

ber o

f peo

ple

in an interaction

Sup

po

rt in maintaining

so

cial contacts (sched

uling,

attending

, particip

ating)

Exam

ples o

f quantifi

ers

Qu

an

tifiers

Tim

e fra

me

EN

GA

GE

ME

NT/

PAR

TICIPA

TION

Passive

Active o

bservatio

n

≤25%

particip

ation

26-50

% p

articipatio

n

51-75% p

articipatio

n

76-9

9%

particip

ation

100

% p

articipatio

n

ME

ASU

RE

ME

NT

Activity leng

th (m

ins) e.g. tim

e taken to

com

plete

online sho

pp

ing

ord

er, time sp

ent eng

aging

with

grand

children

Activity reg

ularity e.g

. times/w

eek co

oking

a meal

Time o

f day

Distance e.g

. walk

to the letter b

ox

Am

ount e.g

. fold

ing

a full basket o

f laund

ry; numb

er o

f falls

Time to

evaluate attainm

ent e.g.

by the end

of the

pro

gram

Ad

apted

from

Bovend

’Eerd

t et al. 200

9

Fig

ure

2: D

em

en

tia-sp

ecific

SM

AR

T F

ram

ew

ork

– exam

ple

do

main

s an

d sc

alin

g fo

r settin

g

SM

AR

T re

ab

lem

en

t go

als a

nd

defin

ing

atta

inm

en

t levels

13E

valu

atin

g re

ab

lem

en

t pro

gra

ms fo

r peo

ple

with

dem

en

tia – C

lient Wo

rkbo

ok

Define – SMART goals using the dementia-specific Framework


3.Sc

ore

– u

sin

g G

AS

-Lig

ht

3. Score - using GAS-Light

a) Prior to beginning the reablementprogram, rate the client’s currentlevel of functioning towards theirSMART goal.

b) At the end of the program (or atanother pre-specified time), rate theclient’s level of attainment towardsthat goal.

Once the goal has been identified (step 1) and the parameters defined ‘SMART’ly (step 2), the GAS-Light scoring system may be applied to determine the client’s level of attainment at the end of their reablement program. Table 2 presents a practical tool for using the GAS-Light approach.6, 9 This tool allows practitioners to score GAS-Light using a verbal description of functioning with no need to apply the numerical scoring system. However, the scoring system has been linked with the verbal scoring system to facilitate broader reablement program monitoring.

The process of applying GAS-Light is as follows:

1. The client’s expected outcome towards thegoal should be recorded (the SMART goalthat has been developed in steps 1 and 2 ofthis guide).

2. Prior to beginning the program (‘baseline’)the client’s level of functioning towards theiridentified goal should be rated as eitherhaving some function (-1) or no function atall (-2; there is no possibility for the client tobecome worse in function towardsthis goal).

3. At the end of the program (‘after reablementprogram’ - or at another pre-specified time),the client’s goal will be revisited and theirlevel of function towards that goal ratedagain. At this point, it will be determinedwhether the goal was achieved as expected(0), a little more than expected (1), a lotmore than expected (2), or if it was notachieved, whether it was partially achievedor no change (-1) or if it got worse (-2).6, 9

For a more detailed guide on using GAS and calculating GAS scores in a rehabilitation setting, see Turner-Stokes (2017).9


3.Sc

ore

– u

sin

g G

AS

-Lig

ht

Table 2: GAS-Light scoring system for people with dementia engaged in a reablement program

Baseline date: Scoring

Regarding the

reablement goal,

do they have

After reablement program – date:

Was the goal

achieved?

No function (as bad as they could be)

Some function

A lot more

A little more

As expected

Partially achieved

No change

Got worse

-2

-1

+2

+1

0

-1

-1/-2

-2

Yes

No

Adapted from Turner-Stokes (2009, 2017)

The following one page reablement plan is to be completed together with your client. This page is for the client to keep so they have a record of their goals and their reablement plan to achieve these goals.

MY REABLEMENT PLAN

Name: Date:

Therapist/ clinician:

This is what I want to work on (my goal):

My program involves: e.g. building strength in my legs, practicing using a timer while cooking ameal

My supporting team: e.g. allied health team members, family members

I am aiming to achieve this goal in: weeks (time frame) (add date)

At the beginning of my program, I have (circle):

• No ability towards my goal

• Some ability towards my goal

At the end of my program, I have (circle):

• Achieved my goal: as expected, a little more, a lot more (circle one)

• Partially achieved my goal

• Not achieved my goal: no change, less ability towards my goal (circleone)

Documents

Client Workbook - Hammond