Nothing distinguishes a rehabilitation setting more than the stated goals of their rehabilitation programs and the outcomes evidence they present in demonstration of success. Next time you have the opportunity to look at a rehabilitation provider’s website compare its goal or mission statement to its link for reported outcomes. If they are not related something is amiss.
Setting goals is an essential part of any rehabilitation program and defines the outcomes to be achieved. The care plan is developed to organize time and resources to structure and guide the rehabilitation process. By precisely agreeing upon what is expected, physicians, nurses, therapists and clinicians develop the plan of care identifying where to concentrate resources and efforts to achieve the outcome with minimal distraction from the plan. Shortly after admission to a rehabilitation program expected outcomes and goals should be the same.
The first goal to be established is the strategic aim of a rehabilitation program. This can vary significantly. For some, a long-term goal would be returning to a completely normal lifestyle. For others, it may be to return home and remain at home with the help of caregivers. The inpatient rehabilitation hospital has a very specific role to play in accelerating the return of the patient to a community living setting. Unlike alternative institutional rehabilitation providers, the inpatient rehabilitation facility is capable of providing a brief intense coordinated plan of interventions specific to overcoming the barriers to discharge home. For the Medicare patient, this is why IRFs exist.
As well as providing a structure, setting appropriate goals provide the motivation required for success. A recent study (J Rehabil Med. 2011 Jan;43(2):156-61.) of elderly rehabilitation patients identified “walking”, “getting rid of pain”, “autonomy” and “returning home” as the most frequently reported goals for this population. At a time when the post acute rehabilitation industry is establishing quality and outcome reporting standards, these goals should be primary in communicating quality comparisons. So far, they have not been included in the discussion.
As fundamental as this may be to an IRF, goal setting is problematic for many clinicians, especially at the program or interdisciplinary team level. CARF and the Joint Commission have evolved standards for goal-directed patient care. A useful way of remembering these is to use the SMART mnemonic. While there are plenty of variants, SMART usually stands for; Specific-Measureable-Attainable-Realistic-Timely.
A difficulty seems to be in the ability to be specific and precise is stating the goal and then determining the appropriate measure to quantify progress or goal attainment. Failing to commit to a measure often erodes the goal setting methodology. The reporting of outcomes then reverts to other sources of data which may not be the primary patient or hospital goal.
As the rehabilitation industry moves to quality reporting to compare providers, we should expect that patient goal attainment will be a primary indicator of effectiveness for rehabiliation. The percent of patients discharged to the community should be the first performance metric we all agree upon.
