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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:
4 Evaluating reablement programs for people with dementia – Client Workbook
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.
5 Evaluating reablement programs for people with dementia – Client Workbook
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
7 Evaluating reablement programs for people with dementia – Client Workbook
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
Choose – from the Reablement Goal Lists
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
Choose – from the Reablement Goal Lists
11 Evaluating reablement programs for people with dementia – Client Workbook
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
12 Evaluating reablement programs for people with dementia – Client Workbook
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
14 Evaluating reablement programs for people with dementia – Client Workbook
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
15 Evaluating reablement programs for people with dementia – Client Workbook
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)