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Jane resides at an assisted living facility, and after being independent, she spent several weeks in inpatient rehab following a series of small strokes. Regardless of where she went—from acute care to her current facility—providers focused her care on goals related to her physical stature and function, from the strength of her arms to her ability to walk independently. While Jane progressed, something was missing. She didn’t seem to be thriving.
Jane’s occupational therapist, Jody, noticed the problem immediately—the goals were always to get well enough to graduate to the next setting, from initial stages in the hospital to skilled care, inpatient rehab, and now home health in an assisted living facility. But the goals never had anything to do with Jane’s personal goals and aspirations. They were solely based on the external financial incentives that drive patients to the least costly setting of care.
Those kinds of goals are useful to an institution, and in some cases, they might prove useful for the patient, but goal-setting is much more important than these flimsy, cost-saving milestones suggest. Provided they are realistic and positive, goals are essential to patients’ recovery.
We should encourage patients to create goals that allow them to actively participate in their own recovery. Combine these three types of goals to help your patients feel better, faster: performance goals, learning goals, and intrinsic goals.
1. Performance Goals
A performance goal is the typical one we focus on in rehabilitation. This is any goal that involves measurable performance and enables patients to have at least some control over associated outcomes. In Jane’s case, Jody instituted performance goals based on objective measures of Jane’s progress in ambulation and strength, including Jane’s ability to hold her grand-child.
For best results, performance goals should always be challenging and highly specific. For example, you might say to a friend that you are going to start running a certain number of miles a day, are planning to double this by the end of the summer, and are aiming to run a certain number of miles in a certain timeframe by autumn.
These goals are the clearest indicators of progress, and they can give patients a much-needed boost. If they start feeling discouraged, you can clearly show them how far they’ve come. Performance goals should help your patients focus their attention on variables under their control, recognize and celebrate incremental improvements, and realize more positive outcomes.
2. Learning Goals
Learning goals are also effectively utilized in healthcare settings, such as rehabilitation; they involve setting specific outcomes, which provide context for predicting performance. For example, Jody prioritized learning goals that would enable Jane to demonstrate proper self-care and management with adaptive equipment, like a walker.
In our chronic pain patients, we set learning goals of mindful breathing techniques to deal with potential pain triggers that can mitigate the deleterious effects of stress. There is a promising trend of dieticians emphasizing learning goals these days. For example, some will take their patients grocery shopping and teach them how to become more proactive in maintaining their health through nutrition and proper food choices.
In our experience, learning goals are still all too often ignored in healthcare where the most common default is to prioritize the requirements of insurance companies over patient-centered care. This is unfortunate because many patients are motivated and driven by learning and often seek us out specifically for prevention, information, and skills rather than just applied interventions.
3. Intrinsic Goals
An intrinsic goal is a goal set by a patient and not by anybody else, like family, friends, culture, or teammates. They are based exclusively to the personal interest of the patient. For this reason, intrinsic goals can inspire passion and commitment and produce outcomes that are more satisfying and meaningful. They may even induce states of flow. “Flow” is the feeling we get when we are lost in time because the task at hand is matched to meeting a challenge. Jane’s intrinsic goal was to be active with her great-grandchild at her neighborhood playground.
Intrinsic goals are far more valuable to the patient than extrinsic goals, which focus on outside validation. For example, a total knee patient requires a certain range of motion, strength, and walking distance. This is far different than that same total knee patient stating that their personal goal is to be able to walk in the park with their mate.
The secret sauce of developing intrinsic goals is to ask questions in a process known as patient inquiry. For example, you might ask your patients:
- How will you benefit from this goal that you are setting for yourself?
- What will it take for you to achieve this goal?
- How will achieving this goal make you feel?
- Why is this goal important to you?
- How will your life be better?
This facilitation is necessary because patients traditionally are not asked about their own goals and desires. Nevertheless, when patients make their own goals explicit, it can empower them to make even greater progress.
Combine All Three Goals
All too often, healthcare practitioners set goals within the very narrow confines of goals mandated by their institutions or other bureaucratic requirements. For example, the typical physical and occupational therapy note, as well as Medicare’s requirements, mandate the use of “short and long-term goals” that are written in a very medicalized fashion.
While there may be compliance and reimbursement rules and regulations associated with certain goals in healthcare, we must work to ensure that they do not interfere with more insightful patient-stated goals. Performance goals are powerful, but they become even more so when they are combined with learning goals and intrinsic goals. My suggestion is to always include a section in your patient notes about their personal aspirations or goals. Patients can have a best-imagined future self if we just remember to ask them.