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PERSON CENTERED AND OUTCOME FOCUSED
Writing Measurable & Person
Centered Goals & Objectives
November 17, 2015
Suzanne M. Gipperich
MORC, Inc.
Mental Health Code
R 330.1712 – Individualized written plan of services.
A treatment plan shall establish meaningful and measurable goals with the recipient.
For Individuals Receiving Habilitation Waiver Services, Goals Should Include The acquisition of the behaviors necessary for the client
to function with as much self determination and
independence as possible; and
The prevention or deceleration of regression or loss of
current optimal functional status.
Things to consider..
What is the area of need for this individual? ¨ How is this area of need related to the individual's disability? What does the circle of supports want this individual to know
or be able to do as a result of this IPOS? What is it about the individual's disability that interferes with
achieving this knowledge or skill? What is the actual (measurable) starting point for this
knowledge or skill? How will we know if the individual can or succeeds at doing
this? What will I see this individual doing when he/she reaches
this goal?
Where go ideas for goals come from? Look at life domains:
Community inclusion and participation-
interesting things to do and people to do them
with
Independence and interdependence learning
to do things for and with others
Productivity or work
PRINCIPLES OF GENTLENESS COMPANIONSHIP,
COMMUNITY & CONNECTION
SAFE AND LOVED OR VALUED
PRAISE & DEMAND
STRUCTURE & TRANSITION
LIFE DOMAINS HOUSING
EDUCATION
EMPLOYMENT
FAMILY
SOCIAL
HEALTH/MEDICAL
SAFETY
DAILY LIVING
EMOTIONAL
/BEHAVIORAL
SPIRITUAL
TRANSPORTATION
CULTURAL/LANGUAGE
DD PROXY Personal Care
Mobility
Eating
Feeding
Grooming
Hygiene
Medication Assistance
Communication
Support Systems
Shopping
Using the phone
Money Skills
Transportation
Banking
Leisure Skills
Meal Preparation
Housekeeping
Laundry
Cooking
SIS By definition what is important TO and FOR
Measures supports to be successful rather than try
to fix or blame what is wrong
Looks at needs versus deficits—
• amount, scope, duration (A)
Minimizing Risks to Health and Safety
The diverse items discussed in the SIS interview allow crisis planning to be more comprehensive.
During the interview, items are flagged as “Important For” based on the consensus of the individual and circle of supports
Utilizing the identified items, individualized safeguards can be created to minimize risk.
Accurate measurement of needed safeguards allows the least restrictive environment to be maintained for each individual.
Setting measurable, meaningful, and achievable goals Data gathered provides building blocks for success
Items flagged as “important to” help inform and enrich the goal setting process
Measurable data assists in meeting the goal-setting standards established by Medicaid
Assisting with transitional planning
A SIS can be requested prior to, during, or following a time of transition
At age 17, individuals who are expecting their support needs to change at age 18 are offered the option of participating in a SIS Interview.
From a family home, out of school…..
A comprehensive snapshot of needed supports can assist in putting necessary building blocks in place to make transitions successful.
SIS STATEMENT INCLUDE SIS RESULTS IN THE
IPOS DISCUSSION
EITHER HAVE A FORMAL GOAL OR ADDRESS IN THE CIRISIS PLAN
REMEMBER… Person centered planning is about getting a
life, not about getting services
Soooo good goals start with good person centered planning
GOALS FOR B3s – MPM Section 17.1 Community Inclusion and
Participation The individual uses community
services and participates in community activities in the same manner as the typical community citizen.
COMMUNITY INCLUSION We all want to have interesting places to go-that
means interesting to us
AND we want to engage or participate to the best of our ability and interact with our LOCAL community
GOALS FOR B3s – MPM Section 17.1….. Independence
How the individual defines the extent of such freedom for him/herself.
How much I can and want to do
AND recognition for it.
INDEPENDENCE We want to have a sense of self efficacy or the sense
that we can do things for ourselves-to the best of our
ability.
For those with significant physical challenges it may be
by making choices,
by ordering or planning their day.
INTERDEPENDENCE……… WE WANT TO BE ABLE TO DO THINGS FOR AND
WITH OTHERS (COMPANIONSHIP AND
CONNECTION)
AND WE NEED RECOGNITION OR TO FEEL
VALUED.
THAT WE HAVE SOME GIFT(s)
TO BRING TO THE TABLE
GOALS FOR B3s – MPM Section 17.1…..
Productivity
Engaged in activities that result in or lead to maintenance of
or increased self-sufficiency and self esteem
Typically going to school and work
Medical necessity – MPM Section 1.7 (B3s) 17 Determination that a specific service is
medically (clinically) appropriate, necessary to
Meet needs, consistent with the person’s
diagnosis, symptomatology and functional
impairments.
Is the most cost-effective option
in the least restrictive environment,
Medical necessity – MPM Section 1.7 (B3s) 17
Is consistent with clinical standards of
care.
Promote community inclusion and
participation, independence, and/or
productivity.
HAB WAIVER GOALS…
Toilet training
Personal hygiene
Dental Hygiene
Eating
Bathing
Dressing
Grooming
Bed mobility
Transferring
Mobility
HAB WAIVER GOALS CONTINUED….
Communication
Receptive
Expressive
Must have at least ONE ACTIVE TREATMENT GOAL to qualify for waiver
If the person only needs verbal assistance/guidance, the skill is not considered to be in need of “active treatment”
Goals for persons with significant disabilities Responding to sensory stimuli -ex sight, taste,
sound or smell (hopefully measuring positive response)
Imitating caregiver action after demonstrations – ex Joe will perform one rubbing motion on his right arm with the wash mitt after staff demonstrates 5 times with hand over hand
Will respond to name – ex by turning head toward caregiver, by making eye contact
Components of a goal Goal statement—broad statement-intangible
Objective(s)—narrower statements action measurable
Methodology-your how to with
AMOUNT: services that support the goal
SCOPE: who, how, what, where, when (methodology)
DURATION: how long the goal or objective will last and the
services to support it
BARRIERS SOLUTIONS
GOAL STATEMENT The broad statement of what we want to accomplish
–usually over a one year period
This involves
A) knowing the individual — their baseline
Where they stand on a given skill on a given or average day (what does it look like?)
B) Knowing how much we can expect them to progress —which leads to your objectives OR the small increments of progress you can reasonably expect
EXAMPLE Lets go back to Andrew wanting to increase his
ability to cook independently from the SIS
His Goal Statement might be:
Andrew will plan and prepare a meal for family
and friends-specifically his mothers lasagne
recipe
Momma Mia’s Lasagne
1 1/2 lb. browned ground beef 1 lg. jar spaghetti sauce 1 1/2 c. water 16 oz. Mozzarella cheese Raw lasagna noodles (3 per layer) Alternate layers: sauce-noodles-cheese in 9 x 12 or 13 pan . Make 3-4 layers. Cover tightly with aluminum foil. Bake 45-60 minutes at 350 degrees.
Objectives - Examples Andrew will shop for the ingredients using his
mother’s lasagne recipe, given verbal instruction /assistance for caregiver on one trial.
Andrew will gather ingredients and necessary cooking utensils, given verbal instruction for 4 out of 5 trials.
Andrew will brown the beef and then drain it, given verbal instruction for 4 out of 5 consecutive trials.
Andrew will layer sauce-noodles-cheese until the pan is full, given verbal instruction for 4 out of 5 consecutive trials.
Andrew will put the lasagne in the pre-heated oven, set the timer for 55 minutes and cook until timer goes off, given verbal instruction for 4 out of 5 consecutive trials .
Objectives - Examples
With the assistance of staff as needed, Andrew will choose an activity in his community in which to participate 2 times per month for 3 consecutive months.
With the use of a picture schedule and no prompts, I will perform my daily self care routine in the morning (shower, brush my teeth and get dressed) prior to leaving for work for 4 weeks.
When asked by staff, I will verbally state one positive aspect of each community activity in which I engage 9 out of 10 consecutive times.
EXAMPLE Amy is also working on increasing cooking skills,
however her goal is to put a sandwich together.
Her shorter term objectives might be to…
A) gather the ingredients-bread, meat, cheese, condiment
B) to assemble the sandwich
C) To package it or to cut it in half
METHODOLOGY SUPPORTS
Andrew might have 1 to 2 hours of cls 2 to 3 days a week.
Amy may need ½ hour of cls 5 days a week if she is making her lunch for work or school
CONDITIONS-PART OF THE DIRECTIONS Andrew is his mother’s recipe card coupled with verbal
instruction (we might also use pictures of the various steps)
Amy is using a template made up of all of the ingredients for a sandwich for her first objective coupled with gestural prompts
METHODOLOGY CONTINUED CONDITIONS…
Where is the learning going to take place?
Real life situations or role playing or a
combination of both?
Social skills are great for role playing before a
social situation.
ID the female bathroom or
Conditions &Measurability …. You can make behavior measurable by defining the
factors surrounding the behavior (conditions).
precipitating events, such as, "when asked to work
independently”
environmental factors, such as, "when dealing with female authority figures”
other patterns, such as "always after lunch," "in the community," “at his place of employment” When interacting with women in the community, Andrew
will maintain appropriate social space and will bring up topics appropriate to the persons present and the situation………
Supports
Natural Supports
Friends
Family
Neighbors
Co-workers
Volunteers
Peers
Church members
Community Supports Can be used by all, not
just those with disabilities
Other “system players”
Schools
Judicial System
Department of Human Services
LETS TALK ABOUT PARTICIPATION Think of it on a continuum from least to most and
define it for that individual
Independently With Gestural
Prompt
With verbal Intermittent
Prompt Physical
Assistance
Continuous Physical Assistance
Performance of a Specific Behavior
Measurable involves action
Observable-you can see
or hear it being done
Behavior
Measurable and Observable
Take
Perform
Complete
Use
List
State
NOT Measurable and Observable
Improve
Understand
Learn
(These can all be
interpreted differently)
LETS TALK ABOUT COMPLETION CRITERIA
How many times does the individual have to do
it?
Are you going for skill building ---competence
OR--Participation?
Imitation or initiation
Completion Criteria continued…
Definition of acceptable performance
Level of accuracy-100% correct?
Individualized for the person based on where they
are now
Duration for success (over what period of time
must the criteria be met?) day, week, month….
Making goals measurable You can also make it measurable by indicating a rate,
3 out of 4 times
80% of the time
5 minutes out of every 10
75% success
When using a rate, be sure you can specify and measure the "whole part." In other words, if you say an individual will do something 80% of the time, specify the time frame, i.e a 15-minute interval, for a week, for a month…..
Could a dead man do the following? To reduce swearing by 90% over a 1 month period. To speak calmly to housemates without swearing
90% of the time over 3 consecutive months. To reduce incidents of stealing to 1 day or less per
month for 6 months. With staff verbal prompts, will calmly engage in
unfamiliar social events at least 4 times per month for 3 months.
Dead Man’s Test Avoid words like: reduce, stop, eliminate,
discontinue… these are all NON-ACTIONS.
AND also create an awareness or focus on what you don’t want, which ends up being all you see! Especially for interactional goals! Behavior plans!
FOCUS INSTEAD on what positive actions or WHAT YOU WANT TO SEE
LETS GO BACK TO ANDREW Andrew’s completion criteria might be
(OBJ A) Cook 3 meals over a 3-month period
given verbal instruction
(OBJ B) Cook 3 meals given just the initial verbal
prompt over a 3-month period
LETS REVISIT AMY… Amy might have the completion criteria to assemble her
sandwich given a gestural prompt for each step (item) 4
out of 5 consecutive trials, or 90% of the trials for one
month. (OBJ A,B,C…)
OBJ A Amy will gather two pieces of bread and place them
on her sandwich template given initial (1) gestural prompt
for 4 out of 5 consecutive trials (or 90% of the trials for 1
month)
METHODOLOGY Instructional style
Whole task or just one step at a time?
Buying a car or a house versus making lasagne?
You’re not going to mix the ingredients or brown the
hamburger and then throw them out..conversely you
probably won’t buy a car or a house the first time out!
INSTRUCTIONAL STYLE Generally, use the least amount of assistance needed for
successful completion
Use the fewest words possible for the training, reserve your
words for praise
Pair words with gestures
Use templates or pictures
ALWAYS do steps in the same order
BARRIERS and SOUTIONS Some can be due to the differing abilities or
motivation of the learner and a good methodology
will address that..
HOWEVER much can be attributed to
CAREGIVER EDUCATION
CAREGIVER ATTITUDES
THE ENVIRONMENT
SPEAKING OF CAREGIVERS
Part of our job is to get caregivers to take
ownership
Get ideas from caregivers who know the
individual best
Start with special interests of the
caregivers
DATA COLLECTION Your data sheet and the data you collect needs to match your
completion criteria.
Calendar sheet
MONDAY/TASK TASK What Dan did How Long Shared Engagement initials
1
2
3
4
5
TUESDAY
1
2
3
4
5
WEDNESDAY
1
2
3
4
5
THURSDAY
1
2
3
4
5
FRIDAY
1
2
3
4
5
John Doe 12345
GOAL I will participate in 5 activities per day for at least 1 minute 50% of the days for a one month period. DATA COLLECTION: Document the task John participated in. What he did and how long and on how you were able to engage John-in a shared interaction, i.e a smile, a hand shake, a back rub, some indicator that John engaged with you personally during the task or at the end of the task.
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Apply toothpaste
Brush front
top/bottom
outside of teeth
30 seconds
Brush front
top/bottom inside
teeth 30 seconds
Brush left side
outside
top/bottom teeth
30 seconds
Brush right
side outside
top/bottom
teeth 30
seconds
MONTH:
YEAR:
Date Int. Data Comments: Date Int. Data Comments:
1 17
2 18
3 19
4 20
5 21
6 22
7 23
8 24
9 25
10 26
11 27
12 28
13 29
14 30
15 31
16
DATA COLLECTION KEY
+ Objective independently completed as written on the first attempt following initial prompt.
- Objective not completed, completed on a later attempt, or assistance was required following initial prompt.
R Continued refusal.
X Not run. State reason in comments section.
Use Comments section for additional information to accurately describe effort.
Caregiver’s Signature Initials Caregiver’s Signature Initials
1. 3.
2. 4.
Data Sheets Make them simple Put the key on the data sheet
Documentation: I=Jane independently did this GP= required a gestural prompt, I,E pointing but nothing
said GI= required gestural instruction or several gestural prompts VP= required one verbal prompt VI= required more than one VP or verbal instruction IPA= intermittent physical assistance CPA = continuous physical assistance.
In-servicing, training and troubleshooting
Run through the goal with the caregivers who will be
teaching
Sometimes videos are helpful
If someone is not making progress, regroup re-think
and rewrite
Areas for Potential Goals
Meal preparation
Laundry
Activities of daily living
Shopping for food and other necessities of daily living
Areas for Potential Goals Money management
Socialization and relationship building
Leisure choice and participation in regular community
activities