Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs

Understanding how older people with mild frailty engage with behaviour change to support their independence: a qualitative study

OBJECTIVES

To explore barriers and facilitators to behaviour change in older people with mild frailty.

DESIGN

Qualitative study.

SETTING

Community-dwelling older people living with mild frailty.

PARTICIPANTS

64 older people with mild frailty, workers delivering the service and stakeholders.

METHODS

Semistructured interviews were conducted between July 2022 and May 2023 with participants in a randomised controlled trial ('HomeHealth') of a 6-month, home-based, personalised goal setting intervention, based around the Capability-Opportunity-Motivation-Behaviour model. We purposively sampled older participants receiving the service (n=49), workers delivering it (n=7) and stakeholders supporting its delivery (n=8). Interviews explored participation experiences, including engagement, perceived progress and impact. Transcripts were analysed using thematic analysis.

RESULTS

Key themes included frailty symptoms and adapting/compensating for these, self-efficacy and beliefs about capacity or need for change, familiarity with goal-setting processes and health-related knowledge, accessibility of services and outdoor environments, and enabling social support. Participants were empowered to change behaviours with support, where personalised meaningful goals were set. These were maintained where they led to a tangible outcome and had increased self-efficacy; however, new health challenges and lack of intrinsic motivation could be barriers.

CONCLUSIONS

Regular and continued empathic person-centred support helps empower mildly frail people who are motivated to change their behaviour. Identifying those willing and able to identify their need for change may be key to maximise service use impact.

TRIAL REGISTRATION NUMBER

ISRCTN54268283.

Exploring Goal Attainment Scaling Among Occupational Therapy Students: A Retrospective Descriptive Analysis

Purpose: This study explored the administration of goal attainment scaling (GAS) by entry-level occupational therapy (OT) students, examining their competency following minimal training. While GAS is valuable for measuring progress toward individualized client goals, its implementation requires specific skills and training that may challenge entry-level practitioners. Method: Using retrospective data from a study of sensory garments' effects on children with autism spectrum disorder (ASD), we analyzed GAS administration by five entry-level OT students. Students received both indirect training through their curriculum and 3 h of direct research-specific preparation. Using a modified version of the GAS checklist, we evaluated students' competency through video recordings of GAS administration sessions and written GAS. Results: Analysis revealed variable competency levels among students. While overall performance met 82.4% of checklist criteria, individual student competency varied considerably (54.5%-95.4%). Three of five students achieved the established 75% competency threshold. Students consistently met criteria for conceptual goal construction and timeframe specification but struggled with maintaining single dimensions of change and specifying observable behaviors. Conclusions: Entry-level OT students demonstrated varying levels of competency in GAS administration following minimal training. Our findings suggest the need for more comprehensive training in specific aspects of GAS, particularly in scale construction and behavioral specification. These results have important implications for how OT programs prepare students to implement GAS in clinical practice.

Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Development of an Assessment Tool to Measure the Quality of Life Goal Setting for Cancer Survivors: A Content Validity Study

INTRODUCTION

An initial version of the Reengagement Life Goal Assessment Tool for Cancer Survivors (ReGAT-C) was designed to measure the quality of life goal-setting practice conducted by responsible healthcare professionals along with nonterminal cancer survivors undergoing inpatient cancer treatment. This study aimed to test content validity of the ReGAT-C and revise it.

METHODS

Eleven experts and nine healthcare professionals participated in this study. Content validity assessments using questionnaires and focus group interviews were conducted with experts. Cognitive interviews were conducted with healthcare professionals. The content validity index was calculated based on expert questionnaires, and these interview data were analyzed by inductive and deductive approaches. When the ReGAT-C was substantially revised, it was retested through questionnaires.

RESULTS

The initial version of the ReGAT-C was substantially revised and three new items were added, resulting in the development of a revised version of the ReGAT-C with 21 items. All participants re-evaluated the ReGAT-C, and the revised version was verified to have content validity.

CONCLUSIONS

The revised ReGAT-C would contribute to enabling healthcare professionals to assess whether they are based on collaboration with cancer survivors and multidisciplinary teams by reflecting on their own life goal-setting practice.

A systematic review of goal attainment scaling implementation practices by caregivers in randomized controlled trials

BACKGROUND

Goal attainment scaling (GAS), an established individualized, patient-centred outcome measure, is used to capture the patient's voice. Although first introduced ~60 years ago, there are few published guidelines for implementing GAS, and almost none for its use when caregivers GAS is implemented with caregiver input. We conducted a systematic review of studies that implemented GAS with caregiver input; and examined variations in GAS implementation, analysis, and reporting.

METHODS

Literature was retrieved from Medline, Embase, Cochrane, PsycInfo and CINAHL databases. We included randomized controlled trials (published between 1968 and November 2022) that used GAS as an outcome measure and involved caregiver input during goal setting.

RESULTS

Of the 2610 studies imported for screening, 21 met the inclusion criteria. Most studies employed GAS as a primary outcome. The majority (76%) had children as study participants. The most common disorders represented were cerebral palsy, developmental disorders, and dementia/Alzheimer's disease. The traditional five-point GAS scale, with levels from -2 to +2, was most often implemented, with -1 level typically being the baseline. However, most studies omitted essential GAS details from their reports including the number of goals set, number of attainment levels and whether any training was given to GAS facilitators.

CONCLUSIONS

GAS with caregiver input has been used in a limited number of randomized controlled trials, primarily in pediatric patients and adults with dementia. There is a variability in GAS implementation and many crucial details related to the specifics of GAS implementation are omitted from reports, which may limit reproducibility. Here we propose catalog that may be utilized when reporting research results pertaining to GAS with caregivers to enhance the application of this patient-centered outcome measure.

Selecting Goals and Target Muscles for Botulinum Toxin A Injection Using the Goal Oriented Facilitated Approach to Spasticity Treatment (GO-FAST) Tool

The objective of this article is to introduce the GO-FAST Tool (developed by the Toxnet group) to clinicians working in the field of neurological rehabilitation, specifically post-stroke spasticity management. The concepts utilized in the Tool and described in this article can be broadly grouped into five topics: the principles of patient-centred goal-setting; an algorithm for setting SMART (specific, measurable, attainable, realistic, and timed) treatment goals; goal-related target muscles and botulinum toxin type A dose determinants; goal attainment follow-up, scoring, and interpretation; and the multimodal approach to spasticity management. The Tool can enhance clinical practice by providing guided assistance with goal-setting and target muscle selection for botulinum toxin type A treatment. It also provides support with the follow-up evaluation of goal attainment and calculation of treatment success. The Tool is designed to be used by clinicians with varying levels of expertise in the field of neurological rehabilitation and post-stroke spasticity management, from those who are new to the field to those with many years of experience. A case study is presented in the Results Section of the article to illustrate the utility of the Tool in setting SMART treatment goals in the management of patients with post-stroke spasticity.

Feasibility of Goal Attainment Scaling as a patient-reported outcome measure for older patients in primary care

BACKGROUND

Goal Attainment Scaling (GAS) is an outcome measure that reflects the perspectives and experiences of patients, consistent with patient-centred care approaches and with the aims of patient-reported outcome measures (PROMs). GAS has been used in a variety of clinical settings, including in geriatric care, but research on its feasibility in primary care practice has been limited. The time required to complete GAS is a barrier to its use by busy primary care clinicians. In this study, we explored the feasibility of lay interviewers completing GAS with older primary care patients.

METHODS

Older adults were recruited from participants of a larger study in five primary care clinics in Alberta and Ontario, Canada. GAS guides were developed based on semi-structured telephone interviews completed by a non-clinician lay interviewer; goals were reviewed in a follow-up interview after six months.

RESULTS

Goal-setting interviews were conducted with 41 participants. GAS follow-up guides could be developed for 40 patients (mean of two goals/patient); follow-up interviews were completed with 29 patients. Mobility-focused goals were the most common goal areas identified.

CONCLUSIONS

Study results suggest that it is feasible for lay interviewers to conduct GAS over the telephone with older primary care patients. This study yielded an inventory of patient goal areas that could be used as a starting point for future goal-setting interviews in primary care. Recommendations are made for use of GAS and for future research in the primary care context.