Patient Goal Setting Research Articles

The effect of physical therapy with goal attainment scaling on gait function in patients with subacute stroke

Background: Correct goal setting for patients is one of the most important aspects of physical therapy. Objective: The purpose of this study was to investigate the effect of physical therapy using goal attainment scaling (GAS) scores to assess the gait function in patients with subacute stroke and related factors. Methods: This retrospective cohort study was conducted using the medical records of 129 patients with subacute stroke who had been treated with intensive rehabilitation intervention. This study was approved by the Institutional Review Board of Bundang Cha Hospital (2021-06-008). The functional ambulation category (FAC) was used to set goals with the involvement of patients and their caregivers after the initial assessment, and raw GAS scores were calculated according to whether the goals were achieved through assessment one month later based on the FAC score. The groups were then divided according to the raw GAS scores (−1, 0, 1, or 2), and the general characteristics and clinical assessment scores were statistically analysed. Results: From our results, there were differences in clinical assessment scores based on raw scores on the GAS ([Formula: see text]) and correlation between raw scores on the GAS and improvement scores on the clinical assessment items ([Formula: see text]). Moreover, when the gait function measured by FAC was used as a GAS in subacute stroke patients, the better the function of Rivermead mobility index ([Formula: see text], [Formula: see text]) and Korean-mini-mental state examination ([Formula: see text], [Formula: see text]) than the other clinical factors, the higher the goal attainment raw score. Conclusion: Functions, including cognitive function, should be included when setting goals to improve the gait function and should be considered when developing the neurological physiotherapy programmes. This study helps physicians and physical therapists who first apply functional gait assessment as a GAS to set the initial goals and improves patient and caregiver motivations by applying GAS to patients with lower initial cognitive levels.

Collaborative goal setting for patients with heart failure based on the ICF to support integrated care

Heart failure (HF), a noncommunicable disease (NCD), is one of the main reasons for hospitalization of older patient groups. The prevalence in adults is estimated to be 1-2% and is described to be increasing in the older population (11,8%). The participatory involvement of clients and relevant professionals in the goal setting process, has shown positive effects related to clients’ adherence and volition and is perceived being key for health-related outcomes.
 A regional telehealth care program for people with HF in Tyrol, Austria aims to ensure, evaluate, and further develop quality of integrated care, interprofessional cooperation and supporting participatory goal setting and, thus, patient adherence. Therefore, an IT-supported ICF-documentation system, based on a regionally developed core set of the International Classification of Functioning, Disability and Health (ICF) was envisioned for persons with HF. 
 ICF offers a framework for the collaboration of health professionals to coordinate their expertise in person-centred, context-sensitive, participation-oriented health care provision. It enables users to structure their diagnostic reasoning along the ICF-domains and categories and to create a multiprofessional tuning along the intervention process, considering relevant aspects of body structures, body functions, activity, participation and personal as well as environmental context factors.
 The implementation process of this IT-based documentation system, using the ICF as a reference model expresses and is intended to facilitate a biopsychosocial understanding of health, functioning and disability within the interprofessional team of cardiologists, specialised nurses, psychologists, training specialists, occupational therapists, and social workers. 
 It further aims to supports a common language and understanding on health within the interdisciplinary team along the corresponding health care settings. Collaborative assessment, goal setting, intervention as well as documentation and evaluation enables the multiprofessional health care team in its interprofessional efforts. 
 Current practice, experiences and reflections relevant to goal setting and intervention planning, integrating any profession-specific perspectives of this regional expert cardio-rehabilitation team were gathered in individual and group expert discussions, thematically analysed and synthesised. 
 An ICF core-set for HF has been developed through a systematic, iterative process for regional use and further development.
 Throughout the joint project of a regional governmental health care provider and two local universities, an interprofessional team of cardiologists, specialised nurses, occupational therapists, psychologists, sport scientists, physiotherapists, and IT- specialists has contributed to these developments up to the current date.
 The ICF has great potential in facilitating collaborative goal setting, offers a frame for a common understanding expressed through person-centered and context-sensitive, participation-oriented language, reasoning, intervention, and evaluation, and thus supports integrated care. 
 The successful introduction of a common language and an intervention-focus explicitly including not only body functions and activities, but also personal and environmental context factors being key for participation and health condition-related outcomes may have positive effects on quality of care as well as the development of sustainable interprofessional team efforts.
 Further development and research by using a shared IT-platform, built on the identified ICF-core set for HF is planned.

Urinary symptoms and female sexual dysfunction in women with type 1 diabetes: the role of depression.

Some reports suggest that women with type 1 diabetes (T1D) have a greater burden of female sexual dysfunction (FSD) than women without T1D, but the etiology of this elevated risk is poorly understood. To examine the associations between FSD and urinary incontinence/lower urinary tract symptoms (UI/LUTS) in women with T1D and to evaluate how depression may mediate these relationships. LUTS and UI symptoms were assessed in women with T1D who participated in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study. Multivariable logistic regression models estimated associations between FSD and UI/LUTS (overall and specific domains) and the impact of depression on these associations. FSD was measured with the Female Sexual Function Index-Reduced. In total, 499 self-reported sexually active women completed validated assessments of sexual and urinary function (mean ± SD age, 47.7 ± 7.6 years; T1D duration, 23.4 ± 5.15 years). FSD was reported in 232 (46%) responders. The frequency of UI and LUTS was 125 (25.1%) and 96 (19.2%), respectively. Neither UI nor its subcategories (urge, stress) were associated with FSD. Although LUTS (odds ratio [OR],1.75; 95% CI, 1.09-2.77) and its symptoms of urgency (OR,1.99; 95% CI, 1.09-3.61) and incomplete emptying (OR,2.44; 95% CI, 1.23-4.85) were associated with FSD, these associations were attenuated following adjustment for depression and antidepressant medication use. Depression indicators were independently associated with FSD overall and across domains. The complex interplay of voiding dysfunction, mental health, and sexual function warrants further investigation to understand the potential implications for patient assessment, goal setting, treatment, and care planning. Data are from a prospective study of individuals with T1D. These results are unable to explore cause-and-effect relationships among LUTS, UI, depression, and FSD. The sample may not be representative of the general population of women with T1D. Because participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study are mostly White, generalizing the findings to other races and to type 2 diabetes may not be appropriate. While exclusion of sexually inactive women likely biases our findings toward the null, this design element permitted study of LUTS and UI in relation to aspects of FSD, the primary objective of this study. The significant associations between LUTS/UI and FSD among middle-aged women with T1D were greatly attenuated when depression was considered a mediating factor.

ID: 209974 Improved Trial Success Using a Novel Patient App for Goal Setting and Digital Education Resources

Recent data has demonstrated that use of a novel digital health application during the SCS trial correlates with improved trial outcomes and shows high patient engagement with the application throughout the trial.1 Enhancing trial success provides an opportunity to give more patients access to SCS therapy, and benefits patients, providers, and payors alike. It is thought that patient education and goal setting play a key role in SCS patient success, both for the trial and implant. However, patients may experience a lack of timely access to appropriate educational resources or may find misleading information through online search.2 Additionally, though individual patient goals are varied, they may not be prompted to set a personalized goal for the trial, and instead focus solely on the standard criteria of pain relief.3 These present potential barriers to treatment success for SCS patients. Thankfully, new digital applications have been developed with patient education and goal setting in mind to provide timely access to quality educational resources and the ability to set personalized treatment goals. In this abstract we explore the impact of viewing educational resources and setting personalized goals in a SCS patient trial application on trial outcomes.

“At the time I only wanted to relieve stress”: Exploring motivation for behaviour change in long-term hypnotic users

BackgroundMotivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. AimExploring primary care patients’ views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and settingA qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. MethodEighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. ResultsThe success of discontinuation interventions does not solely rely on patients’ spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. ConclusionMotivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Editor’s Choice Articles for May

May 2023–something different for a change: after each of the three Editor’s Choices articles, there is additional material that would normally fall within the educational content found in the section called PCCM Connections for Readers. This month I will use my main highlights as a guide to further read about extracorporeal membrane oxygenation (ECMO), delirium, and organization of PICU rounds. WHAT ABOUT THE NEED FOR ECMO IN CHILDREN WITH COVID-19 OR MULTISYSTEM INFLAMMATORY SYNDROME? Bembea MM, Loftis LL, Thiagarajan RR, et al; Overcoming COVID-19 Investigators: Extracorporeal Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs (1). Sixty-three hospitals in 32 US states collaborated in a registry (during March 2020 through December 2021) and now report their experience of using ECMO in children and adolescents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiorespiratory failure. The entire cohort included 2,733 patients, of whom 108 were supported with ECMO. In addition to important information about the time course of care, the authors also show data that add to PCCM’s focus on social determinants of health (2,3), with analyses according to race, ethnicity, healthcare insurance status, and social vulnerability index (1). All these themes are discussed in the accompanying editorial (4), and it is also worth rereading PCCM’s approach to SARS-CoV-2-related research (5): we are committed to innovation and new perspectives, and the 2020/2021 US registry satisfies these criteria. “PCCM Connections” for Readers: Please read the systematic review of support with ECMO during SARS-CoV-2-related cardiorespiratory failure (6). The authors have identified 44 studies (18 observational, four case series, and 22 case reports) involving 110 children receiving ECMO in the period up to March 2022. The review is a comprehensive summary of the literature up to PCCM’s latest edition (1), and the accompanying editorial provides a unique assessment of what these data mean in the wider context of the literature in adults (7). WHAT ABOUT FACTORS ASSOCIATED WITH DELIRIUM DURING CRITICAL ILLNESS: REMEDIABLE OR NOT? Ista E, Traube C, de Neef M, et al; Dutch Multidisciplinary Pediatric Delirium Guideline Group: Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis (8). Clinical research into delirium is a longstanding theme in PCCM. Now, international researchers in this field under the auspices of the Dutch Multidisciplinary Pediatric Delirium Guidelines Group report a systematic review of 1990 to 2022 literature. The authors describe information from 24 studies in which 54 factors were found associated with delirium. In the meta-analysis these findings are reduced to seven factors associated with greater odds of developing delirium during pediatric critical illness (8). In the accompanying editorial our writers propose that it is time to include delirium screening as part of our “vital sign” monitoring (9). “PCCM Connections” for Readers: On a similar theme to delirium prevention, please read the Brief Report describing a single-center, prospective, sleep hygiene quality improvement program in PICU patients eligible for early mobilization (10). There are also interesting details about how the program was organized, which is information that should be read together with the recent practice guideline on prevention and management of delirium (11). WHAT ABOUT ROUNDS AND SETTING AND IMPLEMENTING DAILY GOALS OF CARE? Jones AGR, Friedman S, Vu M, et al: Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project (12). Improved communications between everyone, with a clearly defined plan, is the objective for all PICU patients, families, and the broader healthcare team. My last Editor’s Choice is work carried out in a single-center 12-bedded combined medical and surgical PICU. Here, the authors describe the development and implementation of a low-cost aid, literally writing on a glass door. There is an interesting accompanying editorial, which is both creative and challenging (13). “PCCM Connections” for Readers: We have already discussed an article about organization and goal setting during patient care rounds when considering optimizing sleep hygiene (10). Another article about rounding discussions in this issue examines the impact of unit census and patient acuity on effective discussion (14). Why not enhance your review of the literature on the topic of rounds by looking at similar work in recent issues of PCCM (15–17). Finally, another of this month’s highlights is the narrative essay entitled “Line in the Sand” (18).

Implementation fidelity to a behavioral diabetes prevention intervention in two New York City safety net primary care practices

BackgroundIt is critical to assess implementation fidelity of evidence-based interventions and factors moderating fidelity, to understand the reasons for their success or failure. However, fidelity and fidelity moderators are seldom systematically reported. The study objective was to conduct a concurrent implementation fidelity evaluation and examine fidelity moderators of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, cluster-randomized, controlled trial to test the impact of a Community Health Workers (CHW)-led health coaching intervention to prevent incident type 2 Diabetes Mellitus in New York (NY).MethodsWe applied the Conceptual Framework for Implementation Fidelity to assess implementation fidelity and factors moderating it across the four core intervention components: patient goal setting, education topic coaching, primary care (PC) visits, and referrals to address social determinants of health (SDH), using descriptive statistics and regression models. PC patients with prediabetes receiving care from safety-net patient-centered medical homes (PCMHs) at either, VA NY Harbor or at Bellevue Hospital (BH) were eligible to be randomized into the CHW-led CHORD intervention or usual care. Among 559 patients randomized and enrolled in the intervention group, 79.4% completed the intake survey and were included in the analytic sample for fidelity assessment. Fidelity was measured as coverage, content adherence and frequency of each core component, and the moderators assessed were implementation site and patient activation measure.ResultsContent adherence was high for three components with nearly 80.0% of patients setting ≥ 1 goal, having ≥ 1 PC visit and receiving ≥ 1 education session. Only 45.0% patients received ≥ 1 SDH referral. After adjusting for patient gender, language, race, ethnicity, and age, the implementation site moderated adherence to goal setting (77.4% BH vs. 87.7% VA), educational coaching (78.9% BH vs. 88.3% VA), number of successful CHW-patient encounters (6 BH vs 4 VA) and percent of patients receiving all four components (41.1% BH vs. 25.7% VA).ConclusionsThe fidelity to the four CHORD intervention components differed between the two implementation sites, demonstrating the challenges in implementing complex evidence-based interventions in different settings. Our findings underscore the importance of measuring implementation fidelity in contextualizing the outcomes of randomized trials of complex multi-site behavioral interventions.Trial registrationThe trial was registered with ClinicalTrials.gov on 30/12/2016 and the registration number is NCT03006666.

Frequency of Goal Setting Contact with Physical Therapists Is Associated with Orthotist’s Perceived Skill Level

ABSTRACT Introduction Effective communication is key to the development of a successful interdisciplinary team, and effective communication cannot be achieved without an accurate understanding of role awareness. Communication within interdisciplinary teams may be particularly important for orthotists given their highly specialized scope of practice, the limited public awareness of the profession, and relatively recent increases to minimum education requirements. Because physical therapists (PTs) and orthotists commonly work together to restore mobility, the purpose of this study was to determine if there are factors associated with the perceived value of orthotists as members of the health care team among PTs. Materials and Methods This study consisted of a cross-sectional survey assessing demographic characteristics and four value variables. The survey was distributed via email using snowball sampling to health care team members. Responses from PTs were analyzed through a series of statistical testing for significant correlations of the demographic characteristics and value variables. Results A total of 68 responses from PTs were included in the final analysis. Mutual patient goal setting contact showed a statistically significant relationship with frequency of contact and the perceived skill level of orthotists. The mean orthotist skill level was 86.57 (±10.24, min = 59, max = 100). The frequency of mutual patient goal setting contact was higher for PTs who were younger, had a higher level of education, and fewer years of experience. Conclusions Despite its rich history, orthotics may be considered relatively new as a profession, and orthotists are often still establishing their role within a team setting. Mutual patient goal setting may provide a key opportunity for orthotists to increase awareness of their skill set and demonstrate their value as professional members of the health care team. Interprofessional education is another opportunity to increase role awareness and may explain why younger PTs with higher levels of education and fewer years of experience were more likely to set mutual patient goals with orthotists. Clinical Relevance The results of this study show that engaging in mutual patient goal setting with PTs may be an avenue for orthotists to demonstrate their skills, knowledge, and, ultimately, their value.

Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project.

To develop and implement a tool to improve daily patient goal setting, team collaboration and communication. Quality improvement implementation project. Tertiary-level PICU. Inpatient children less than 18 years old requiring ICU level care. A "Glass Door" daily goals communication tool located in the door front of each patient room. We used Pronovost's 4 E's model to implement the Glass Door. Primary outcomes were uptake of goal setting, healthcare team discussion rate around goals, rounding efficiency, acceptability and sustainability of the Glass Door. The total implementation duration from engagement to evaluation of sustainability was 24 months. Goal setting increased significantly from 22.9% to 90.7% ( p < 0.01) patient-days using the Glass Door compared to a paper-based daily goals checklist (DGC). One-year post implementation, the uptake was sustained at 93.1% ( p = 0.04). Rounding time decreased from a median of 11.7 minutes (95% CI, 10.9-12.4 min) to 7.5 minutes (95% CI, 6.9-7.9 min) per patient post-implementation ( p < 0.01). Goal discussions on ward rounds increased overall from 40.1% to 58.5% ( p < 0.01). Ninety-one percent of team members perceive that the Glass Door improves communication for patient care, and 80% preferred the Glass Door to the DGC for communicating patient goals with other team members. Sixty-six percent of family members found the Glass Door helpful in understanding the daily plan and 83% found it helpful in ensuring thorough discussion among the PICU team. The Glass Door is a highly visible tool that can improve patient goal setting and collaborative team discussion with good uptake and acceptability among healthcare team members and patient families.

Patient-reported goal achievements after pelvic floor muscle training versus pessary in women with pelvic organ prolapse. A randomised controlled trial

The aim was to assess the achievement by self-determined goals in pelvic organ prolapse (POP) participants receiving pelvic floor muscle training (PFMT) compared to vaginal pessary. Forty participants with POP stage II to III were randomly allocated to pessary or PFMT. Participants were asked to list up 3 goals they expected from treatment. Thai version of Prolapse Quality of Life Questionnaire (P-QOL) and Pelvic Organ Prolapse Incontinence Sexual Questionnaire, IUGA-revised (PISQ-IR) were completed at 0 and 6-week period. At 6-week post-treatment, they were asked if their goals had been achieved. The totally achieved goals in the vaginal pessary group were 70% (14/20) significantly higher than PFMT group at 30% (6/20) (p = 0.01). The mean ± SD of the post-treatment P-QOL score in the vaginal pessary group was significantly lower than the PFMT group (13.90 ± 10.83 vs 22.04 ± 5.93, p = 0.01), but not different in all PISQ-IR subscales. Pessary treatment for POP yielded better total goal achievements and better quality of life than PFMT for POP treatment at a 6-week follow-up. Impact statement What is already known on this subject? Pelvic organ prolapse (POP) can severely affect the quality of life, causing physical, social, psychological, occupational, and/or sexual dysfunction. Individual patient goal setting and goal achievement scaling (GAS) offers a new method of patient-reported outcome measurement (PRO) in therapeutic success such as pessary or surgery in patient with POP. But there is no randomised controlled trial comparing pessary vs pelvic floor muscle training (PFMT) using GAS as the outcome measurement. What do the results of this study add? The results showed that women with POP stage II to III who received vaginal pessary had higher totally goal achievements and better quality of life than the women received the PFMT at 6-week follow up. What are the implications of these findings for clinical practice and/or further research? The information about the better goal achievements by using pessary can be used as the tools for counselling for patients with POP for selecting the choices for the treatment in the clinical setting.

Effects of Stroke Rehabilitation Using Gait Robot-Assisted Training and Person-Centered Goal Setting: A Single Blinded Pilot Study

Many stroke survivors have difficulties due to the mobility and activities required in daily living. A walking impairment negatively affects the independent lifestyle of stroke patients, requiring intensive post-stroke rehabilitation. Therefore, the purpose of this study was to examine the effects of stroke rehabilitation using gait robot-assisted training and person-centered goal setting on mobility, the activities of daily living, stroke self-efficacy, and health-related QoL in stroke patients with hemiplegia. An assessor-blinded quasi-experimental study with a pre-posttest nonequivalent control group was used. Participants who were admitted to the hospital with a gait robot-assisted training system were assigned to the experimental group, and those without gait robots were assigned to the control group. Sixty stroke patients with hemiplegia from two hospitals specialized in post-stroke rehabilitation participated. Stroke rehabilitation using gait robot-assisted training and person-centered goal setting for stroke patients with hemiplegia was conducted for a total of six weeks. There were significant differences between the experimental group and control group in the Functional Ambulation Category (t = 2.89, p = 0.005), balance (t = 3.73, p < 0.001), Timed Up and Go (t = -2.27, p = 0.027), Korean Modified Barthel Index (t = 2.58, p = 0.012), 10 m Walking test (t = -2.27, p = 0.040), stroke self-efficacy (t = 2.23, p = 0.030), and health-related quality of life (t = 4.90, p < 0.001). A gait robot-assisted rehabilitation using goal setting for stroke patients with hemiplegia improved gait ability, balance ability, stroke self-efficacy, and health-related quality of life in stroke patients.

Cardiac rehabilitation adherence: A multifaceted approach

Cardiac rehabilitation programs are crucial components of cardiac care, aiming to optimize the recovery of patients after cardiac surgery. Within these programs, physiotherapists play a pivotal role in guiding patients through exercise regimens, lifestyle modifications, and the management of pharmacotherapy. Despite their essential role, there remains a limited exploration of the knowledge, attitude, and practice of physiotherapists concerning cardiac rehabilitation program adherence, with a particular focus on the integration of pharmacotherapy, among patients discharged from Indian hospitals after cardiac surgery. This study conducted a structured analysis to comprehensively assess physiotherapists’ knowledge of cardiac rehabilitation guidelines, their attitudes toward patient adherence, and their practices in promoting adherence, taking into consideration the pharmacotherapeutic aspect. Preliminary findings reveal that a substantial proportion of physiotherapists possess an adequate knowledge of cardiac rehabilitation guidelines, emphasizing the significance of exercise, risk factor management, psychosocial support, and medication management. Attitudes toward patient adherence were predominantly positive, reflecting a strong belief in the program’s efficacy in improving patient outcomes. However, it is noteworthy that certain barriers to adherence, including patient motivation, resource limitations, and cultural factors, were identified. In practice, physiotherapists employ diverse strategies, encompassing patient education, exercise supervision, goal setting, and pharmacotherapeutic guidance, to enhance adherence among discharged patients. This review provides valuable insights into the knowledge, attitude, and practice of physiotherapists concerning cardiac rehabilitation program adherence, emphasizing the integration of pharmacotherapy, among patients following cardiac surgery in India. While physiotherapists exhibit robust knowledge and positive attitudes, challenges related to patient motivation and resource constraints warrant dedicated attention. These findings underscore the imperative need for targeted interventions and resource allocation to enhance adherence to cardiac rehabilitation programs, ultimately contributing to improved postoperative outcomes for cardiac surgery patients in India. Furthermore, further research is essential to explore the patient perspective comprehensively and establish a holistic approach to cardiac rehabilitation adherence that seamlessly incorporates pharmacotherapy.

Development and field testing of a standardised goal setting package for person-centred discharge care planning in stroke

Develop and test a person-centred goal-setting package for discharge care planning in acute and rehabilitation stroke units. A multidisciplinary, expert working group (n = 15), and consumer group (n = 4) was convened. A multistage iterative approach was used to develop and test the package. Stages included: (i) contextual understanding, (ii) package development, and (iii) clinician training and field-testing in acute and rehabilitation settings. Observational field notes were taken and clinicians' perspectives captured using semi-structured focus groups post-testing. The final package included a 34-item menu aligned with a manual containing: guideline summaries; common goals; goal metrics based on the SMART Goal Evaluation Method (SMART-GEM); evidence-based strategies; and worked examples. Twenty-three clinicians attended training. Clinician observations (n = 5) indicated that: the package could be incorporated into practice; a range of person-centred goals were set; and opportunities provided to raise additional issues. Clinician feedback (n = 8) suggested the package was useful and facilitated person-centred goal-setting. Enablers included potential for incorporation into existing processes and beliefs that it promoted person-centred care. Barriers included additional time. The package demonstrated potential to facilitate comprehensive person-centred goal-setting for patients with stroke. We developed an innovative approach to support structured person-centred goal setting in clinical and research settings.

Patient-centered goal setting in very early supported discharge with continued rehabilitation after stroke

Purpose To examine patients’ perception of performance and satisfaction with the activities in their set goals before and after very early supported discharge (VESD) with continued rehabilitation. Materials and methods A descriptive cohort study with data extracted from a randomized controlled trial. Sixty-nine patient allocated to the intervention group were eligible. Before discharge, the patients were asked to set rehabilitation goals, and they were asked to rate the performance and satisfaction of their set goals. At discharge from the rehabilitation, the patients were asked to re-evaluate their experience and satisfaction with the goal performance. Results One hundred and forty goals were registered. At 81.5% of the set goals, the patients estimated that they performed the task better at discharge than at enrolment and at 86.5% of the set goals the patients were more satisfied with the performance at discharge than at enrolment. Conclusions Patients with mild to moderate stroke, undergoing a VESD after stroke, reported high performance level for their set goals and were satisfied with their performance execution. Further research is needed to investigate whether the goal should be set preferably at home or at hospital before discharge. Implications for rehabilitation Many of the patients can formulate achievable goals with their rehabilitation after stroke. Patients ongoing rehabilitation after stroke are satisfied with their performance of the set goals. As part of patient-centered care, stroke patients should be given the opportunity to formulate their own goals with their rehabilitation. Short hospital times and fast planning of goal-meetings, seems to influence patient goal setting in early discharge rehabilitation.

Self-management goals of cancer survivors with an ostomy.

Ostomies due to cancer surgery impose complex and enduring care challenges that necessitate cancer survivors" self-management. The objective of this analysis is to evaluate ostomates' self- management goals using a qualitative approach. A multi-site randomized controlled trial testing the Ostomy Self-Management Training program (OSMT) was delivered via telehealth to a group of cancer survivors with an ostomy randomized to either the OSMT program with goal setting or usual care (UC), without goal setting. Goals were classified by type and frequency according to a modified City of Hope Health-Related Quality of Life framework (physical, psychological, social, spiritual, ostomy-specific, and healthcare quality domains), using a directed and systematic content analysis approach. The 524 self-management goals analyzed by domain frequencies physical (29.4%), ostomy specific (29.0%) and social well-being (25.0%) were predominant. Managing other health issues (7.6%), psychological issues (6.0%), and spiritual well-being issues (3.0%) were next. Common self-management themes were ostomy care independence (87.5%), handling cancer-related issues (62.5%), achieving acceptance (56.2%), resuming physical activity (43.0%), and maintaining fluid/diet balance (43.0%). Goal-setting offers insights into self-management concerns of cancer survivors with ostomies. Results demonstrate the broad aspects of self-management ostomates face. Self-management training with patient goal-setting may be used to help ostomates with cancer and their health care providers identify areas for needed education and support.

Baseline presentation and goal setting for patients undergoing treatment for lower limb spasticity with abobotulinumtoxinA in routine practice. Data from the AboLiSh study (S10.003)

Baseline presentation and goal setting for patients undergoing treatment for lower limb spasticity with abobotulinumtoxinA in routine practice. Data from the AboLiSh study (S10.003)

Impact of ambulatory palliative care on symptoms and service outcomes in cancer patients: a retrospective cohort study

BackgroundThe integration of palliative care into routine cancer care has allowed for improved symptom control, relationship building and goal setting for patients and families. This study aimed to assess the efficacy of an ambulatory palliative care clinic on improving symptom burden and service outcomes for patients with cancer.MethodsA retrospective review of data of cancer patients who attended an ambulatory care clinic and completed the Symptom Assessment Scale between January 2015 and December 2019. We classified moderate to severe symptoms as clinically significant. Clinically meaningful improvement in symptoms (excluding pain) was defined by a ≥ 1-point reduction from baseline and pain treatment response was defined as a ≥ 2-point or ≥ 30% reduction from baseline.ResultsA total of 249 patients met the inclusion criteria. The most common cancer diagnosis was gastrointestinal (32%) and the median time between the initial and follow-up clinic was 4 weeks. The prevalence of clinically significant symptoms at baseline varied from 28% for nausea to 88% for fatigue, with 23% of the cohort requiring acute admission due to unstable physical/psychosocial symptoms. There was significant improvement noted in sleep (p < 0.001), pain (p = 0.002), wellbeing (p < 0.001), and overall symptom composite scores (p = 0.028). Despite 18–28% of patients achieving clinically meaningful symptom improvement, 18–66.3% of those with moderate to severe symptoms at baseline continued to have clinically significant symptoms on follow-up. A third of patients had opioid and/or adjuvant analgesic initiated/titrated, with 39% educated on pain management. Goals of care (31%), insight (28%) and psychosocial/existential issues (27%) were commonly explored.ConclusionsThis study highlights the burden of symptoms in a cohort of ambulatory palliative care patients and the opportunity such services can provide for education, psychosocial care and future planning. Additionally routine screening of cohorts of oncology patients using validated scales may identify patients who would benefit from early ambulatory palliative care.

Journey to Transplant: Developing a social support network counselling intervention to improve kidney transplantation.

ContextKidney transplant is superior to dialysis for the treatment of end‐stage kidney disease, but accessing transplant requires high patient engagement to overcome barriers. We sought to develop an educational counselling intervention for patients along with their social support networks to help patients access the waiting list.MethodsUtilizing an Intervention Mapping approach, we established a conceptual framework to develop a behavioural intervention that can be reproduced across kidney transplant centres. The approach includes needs assessment, identifying behavioural determinants and process objectives and integrating targeted behavioural change theory.ResultsThe Intervention Mapping process resulted in the development of a group counselling session, titled Journey to Transplant (JtT). This intervention was designed for kidney transplant candidates along with members of their social support networks and guided by a transplant healthcare professional. The session begins with standardized educational information to improve knowledge and normalize emotional barriers to transplant. This education is followed by a tailored counselling intervention, including the presentation of the individual patient's calculated likely outcomes on the kidney transplant waiting list. Finally, JtT incorporates patient and support network goal setting to address the specific barriers for that patient in accessing kidney transplantation.ConclusionA systematic Intervention Mapping approach to develop the JtT intervention helps ensure the intervention is efficacious, acceptable and feasible for transplant centres to implement. JtT engages the patient's social support network, targeting known barriers to transplant and utilizing established behaviour change theory to motivate concrete actions to improve the likelihood of kidney transplantation.Patient or Public ContributionThis study includes a patient and family advisory committee comprised of kidney transplant candidates and their family members to guide the final language and content of the intervention guide, and the conduct of the implementation and pilot testing of the intervention. However, patients and family members were not involved in the intervention mapping development process itself described in this manuscript, which was informed by focus group data from patient and family study participants.

Quality improvement project to improve providers’ goal-setting activity for chronic disease self-management

BackgroundPatient-centered medical home (PCMH) places patients at the center of care and actively considers patients’ goals, preferences and skill levels in caring for their disease while developing a care plan. We implemented a quality improvement (QI) project to improve internal medicine resident goal-setting activity with patients for chronic disease self-management. MethodsThe plan-do-study-act (PDSA) model was used and a root cause analysis was conducted with internal medicine residents (n=20) and faculty (n=7) to identify barriers to patient goal setting. Two main causes were identified – lack of awareness and lack of knowledge about where and how to set patient goals in the electronic medical record (EMR). Reminders during daily morning huddles, discussions with faculty, educational video presentation and organizational policy change interventions were implemented in four serial PDSA cycles. ResultsThe goal setting activity documentation rate by resident providers increased to 14% following inclusion of patient goal setting reminders during daily morning huddles. There was notable increase in the goal setting documentation rate to 29% following discussion in faculty meeting. The goal setting documentation rate remained the same (29%) despite educational video and policy change intervention. However, goal setting documentation rate increased to 33% by the end of the study. ConclusionOur QI project resulted in a measurable increase in the use of methods of healthcare delivery associated with improved outcomes. This model worked well in our setting, and sharing our success may benefit others seeking to achieve similar goals.

Feasibility of Delivering Pediatric-to-Adult Transition Education during Annual Comprehensive Clinic Appointments and Patient-Reported Outcomes: A Quality Improvement Study

Individuals with bleeding disorder diagnoses require developmentally sensitive care across the lifespan, particularly as they gain knowledge and skills necessary to successfully tackle their illness-specific needs as independent adults (Breakey et al., 2010). The current study describes one phase of a larger quality improvement (QI) initiative aimed at improving transition from pediatric to adult care (TAC) at one US Hemophilia and Thrombosis Center (HTC). Our aim was to assess the feasibility of delivering transition specific education to youth-caregiver dyads during youth annual multidisciplinary clinic appointments. Youth-caregiver dyads were selected given previous research revealing that both patients and their parents express worries about related to TAC (Geerts et al., 2008). Education included discussion of the knowledge and skills necessary for autonomous management of one's bleeding disorder (e.g., illness basics, treatment, communication, and healthy living). During an 8-month period, 101 youth-caregiver dyads were approached. Patients were between the ages of 12 and 25 (M age = 17.66, SD = 3.45). Approximately half of patients were diagnosed with hemophilia A (53.5%) and 16.8% were female. Of the 101 patients approached, 90 completed the transition education discussion. On average, these discussions took 12.80 minutes (SD = 8.49) and ranged from 5 to 50 minutes. Social work delivered the bulk of these discussions (78.7%) and spent an average of 10.61 minutes (SD = 5.76) with youth and caregivers. While the intention was to deliver transition education to youth-caregiver dyads, this only occurred in 37 discussions. Other discussions included the patient only (n = 31), caregiver only (n = 20), or had missing data (n = 1). In instances when a youth-caregiver dyad was approached, but a discussion did not take place, barriers to completing the discussion were identified. “Provider” was listed most frequently (n = 5) as a barrier (e.g., youth sent home by medical team prior to transition discussion occurring; miscommunication between members of multidisciplinary team; low staffing of those trained to deliver transition discussion). Even in instances when a transition discussion did take place, barriers to having the discussion were identified. “Patient” barriers were the most frequently listed (n = 13), followed by barriers related to “Time” (n = 11), and barriers related to “Clinic” (n = 3). At the end of the transition discussion, youth and/or caregivers were encouraged to identify a goal for improving their skills or knowledge in one of the four areas discussed during their appointment. Of those having transition discussions, 72 created a transition goal. The majority of participants reported goals related to Treatment (e.g., infusion skills; n = 36) followed by goals related to Communication (n = 18), Healthy Living (n = 11), and Bleeding Disorder Basics (n = 7). There was a statistically significant difference in the type of goal of expressed by youth and/or caregivers when the patient was 17 years old or younger vs those older than 18, X 2 (3, N = 72) = 9.49, p = 0.024. Generally, more youth reported goals related to Treatment (e.g., infusion skills) than predicted by chance in both age groups. Patients or patient caregivers were contacted via phone between 5 and 14 months following their transition discussion. Approximately 1/3 of the patients who completed transition discussion, responded and provided ratings on progress toward meeting their transition goal. Ratings (M = 4.24, SD = 2.63) were made on a Likert-type scale ranging from 1 (no progress made) to 10 (maximum progress made). The information gleaned from this QI initiative revealed that delivery of transition-specific education within the CU-HTC annual multidisciplinary appointments is feasible and in some cases, served as the impetus necessary for accomplishing transition-specific goals. The results from this initiative have been instrumental in subsequent transition-related efforts related to: (a) fostering full engagement across the multidisciplinary team in TAC efforts utilizing HEMO-Milestones Tool (Croteau et al., 2016); (b) adopting specific materials developed to assess TAC in individuals with bleeding disorder diagnoses (i.e., American Society of Hematology Hemophilia Transition Readiness Assessment); and (c) reducing time between patient goal-setting and follow-up from the HTC. DisclosuresWang: Novo Nordisk: Consultancy, Other: Clinical trial investigator; Bioverativ: Consultancy, Other: Clinical trial investigator; Bayer: Consultancy, Other: Clinical trial investigator; Octapharma: Other; uniQure: Consultancy, Other: Clinical trial investigator; Pfizer/Spark: Other: clinical trial investigator; Genentech: Consultancy, Other: Clinical trial investigator; BioMarin: Consultancy, Other: Clinical trial investigator; CSL Behring: Consultancy, Other: Clinical trial investigator; Takeda: Consultancy, Other: Clinical trial investigator; Hema Biologics: Consultancy, Other: Clinical trial investigator. Buckner: CSL Behring: Honoraria; Tremeau Pharmaceuticals: Consultancy, Honoraria; Genetech: Honoraria; Bayer: Honoraria; Spark: Honoraria; Sanofi: Honoraria; Novo Nordisk: Honoraria; Pfizer: Honoraria; BioMarin: Consultancy, Honoraria; Takeda: Honoraria; American Thrombosis: Membership on an entity's Board of Directors or advisory committees; Hemostasis Network: Membership on an entity's Board of Directors or advisory committees; uniQure: Consultancy, Honoraria.