Home Health & Hospice

Q: Can you share some tips for writing goals for the long-term patient?

Homecare Insider, April 1, 2013

Q: Can you share some tips for writing goals for the long-term patient?

A: Some patients—for example, those with pernicious anemia (vitamin B12 injections) or a neurogenic bladder (catheter changes)—will receive services for an ongoing period of time. Writing goals for these patients can create a challenge because they are not candidates for discharge or dramatic improvement. In most cases, maintenance of their current abilities or status is the focus of care.

Consider these tips when writing goals for the long-term patient:

  • Use ongoing goals (continuing without termination or interruption) or maintenance goals (keeping in a specified state or position).
  • Use the patient as the subject in the goal. In other words, don’t use process-oriented statements. Example: Patient will receive monthly catheter changes. This is not an expected outcome but rather a statement of what the staff will do for the patient. Goals should reflect the patient’s ­condition or abilities. Example: Patient will demonstrate ­techniques for catheter care and irrigation.
  • Use verbs such as “maintain” or “stabilize” to ­highlight the nature of goals for long-term patients.
  • Identify methods to quantify ongoing/maintenance goals. One suggestion is to use selected OASIS data ­elements that focus on stabilization of the patient’s abilities. Consider the patient who receives home health aide services for personal care. Instead of ­setting a goal such as “personal care needs will be met” (a process statement), you should say “patient will demonstrate stabilization in bathing.” OASIS data element M0670, Bathing, serves as the quantifier for this goal and ties it into the plan of care.
  • In situations when an OASIS data element does not apply to the patient, include specific, measurable language relevant to the plan of care. Example: The patient receives daily visits for insulin administration. One goal reflects maintenance of the patient’s blood sugar between two established parameters.
  • Establish a method for writing target dates for these goals. One approach is to enter a date for review of the goals and the plan of care. The target date is the date by which staff will evaluate the effectiveness of the plan. This review will most likely occur when the clinician evaluates the patient’s status and plan at the time of recertification.
  • Verify that the agency’s policy and procedure includes all the specifics to support its approach for long-term patients.

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