PERSON CENTERED AND OUTCOME FOCUSED

Writing Measurable & Person

Centered Goals & Objectives

November 17, 2015

Suzanne M. Gipperich

MORC, Inc.

WHAT MAKES THIS PERSON WANT TO GET OUT OF BED IN THE MORNING?

Mental Health Code

R 330.1712 – Individualized written plan of services.

A treatment plan shall establish meaningful and measurable goals with the recipient.

For Individuals Receiving Habilitation Waiver Services, Goals Should Include The acquisition of the behaviors necessary for the client

to function with as much self determination and

independence as possible; and

The prevention or deceleration of regression or loss of

current optimal functional status.

Things to consider..

What is the area of need for this individual? ¨ How is this area of need related to the individual's disability? What does the circle of supports want this individual to know

or be able to do as a result of this IPOS? What is it about the individual's disability that interferes with

achieving this knowledge or skill? What is the actual (measurable) starting point for this

knowledge or skill? How will we know if the individual can or succeeds at doing

this? What will I see this individual doing when he/she reaches

this goal?

Where go ideas for goals come from? Look at life domains:

Community inclusion and participation-

interesting things to do and people to do them

with

Independence and interdependence learning

to do things for and with others

Productivity or work

PRINCIPLES OF GENTLENESS COMPANIONSHIP,

COMMUNITY & CONNECTION

SAFE AND LOVED OR VALUED

PRAISE & DEMAND

STRUCTURE & TRANSITION

LIFE DOMAINS HOUSING

EDUCATION

EMPLOYMENT

FAMILY

SOCIAL

HEALTH/MEDICAL

SAFETY

DAILY LIVING

EMOTIONAL

/BEHAVIORAL

SPIRITUAL

TRANSPORTATION

CULTURAL/LANGUAGE

DD PROXY Personal Care

Mobility

Eating

Feeding

Grooming

Hygiene

Medication Assistance

Communication

Support Systems

Shopping

Using the phone

Money Skills

Transportation

Banking

Leisure Skills

Meal Preparation

Housekeeping

Laundry

Cooking

SIS By definition what is important TO and FOR

Measures supports to be successful rather than try

to fix or blame what is wrong

Looks at needs versus deficits—

• amount, scope, duration (A)

Minimizing Risks to Health and Safety

The diverse items discussed in the SIS interview allow crisis planning to be more comprehensive.

During the interview, items are flagged as “Important For” based on the consensus of the individual and circle of supports

Utilizing the identified items, individualized safeguards can be created to minimize risk.

Accurate measurement of needed safeguards allows the least restrictive environment to be maintained for each individual.

Setting measurable, meaningful, and achievable goals Data gathered provides building blocks for success

Items flagged as “important to” help inform and enrich the goal setting process

Measurable data assists in meeting the goal-setting standards established by Medicaid

Assisting with transitional planning

A SIS can be requested prior to, during, or following a time of transition

At age 17, individuals who are expecting their support needs to change at age 18 are offered the option of participating in a SIS Interview.

From a family home, out of school…..

A comprehensive snapshot of needed supports can assist in putting necessary building blocks in place to make transitions successful.

SIS STATEMENT INCLUDE SIS RESULTS IN THE

IPOS DISCUSSION

EITHER HAVE A FORMAL GOAL OR ADDRESS IN THE CIRISIS PLAN

REMEMBER… Person centered planning is about getting a

life, not about getting services

Soooo good goals start with good person centered planning

MOST IMPORTANT TO THE INDIVIDUAL

GOALS FOR B3s – MPM Section 17.1 Community Inclusion and

Participation The individual uses community

services and participates in community activities in the same manner as the typical community citizen.

COMMUNITY INCLUSION We all want to have interesting places to go-that

means interesting to us

AND we want to engage or participate to the best of our ability and interact with our LOCAL community

GOALS FOR B3s – MPM Section 17.1….. Independence

How the individual defines the extent of such freedom for him/herself.

How much I can and want to do

AND recognition for it.

INDEPENDENCE We want to have a sense of self efficacy or the sense

that we can do things for ourselves-to the best of our

ability.

For those with significant physical challenges it may be

by making choices,

by ordering or planning their day.

INTERDEPENDENCE……… WE WANT TO BE ABLE TO DO THINGS FOR AND

WITH OTHERS (COMPANIONSHIP AND

CONNECTION)

AND WE NEED RECOGNITION OR TO FEEL

VALUED.

THAT WE HAVE SOME GIFT(s)

TO BRING TO THE TABLE

GOALS FOR B3s – MPM Section 17.1…..

Productivity

Engaged in activities that result in or lead to maintenance of

or increased self-sufficiency and self esteem

Typically going to school and work

PRODUCTIVITY

Job

Volunteering

To give back to our community

Medical necessity – MPM Section 1.7 (B3s) 17 Determination that a specific service is

medically (clinically) appropriate, necessary to

Meet needs, consistent with the person’s

diagnosis, symptomatology and functional

impairments.

Is the most cost-effective option

in the least restrictive environment,

Medical necessity – MPM Section 1.7 (B3s) 17

Is consistent with clinical standards of

care.

Promote community inclusion and

participation, independence, and/or

productivity.

HAB WAIVER GOALS…

Toilet training

Personal hygiene

Dental Hygiene

Eating

Bathing

Dressing

Grooming

Bed mobility

Transferring

Mobility

HAB WAIVER GOALS CONTINUED….

Communication

Receptive

Expressive

Must have at least ONE ACTIVE TREATMENT GOAL to qualify for waiver

If the person only needs verbal assistance/guidance, the skill is not considered to be in need of “active treatment”

Goals for persons with significant disabilities Responding to sensory stimuli -ex sight, taste,

sound or smell (hopefully measuring positive response)

Imitating caregiver action after demonstrations – ex Joe will perform one rubbing motion on his right arm with the wash mitt after staff demonstrates 5 times with hand over hand

Will respond to name – ex by turning head toward caregiver, by making eye contact

Components of a goal Goal statement—broad statement-intangible

Objective(s)—narrower statements action measurable

Methodology-your how to with

AMOUNT: services that support the goal

SCOPE: who, how, what, where, when (methodology)

DURATION: how long the goal or objective will last and the

services to support it

BARRIERS SOLUTIONS

GOAL STATEMENT The broad statement of what we want to accomplish

–usually over a one year period

This involves

A) knowing the individual — their baseline

Where they stand on a given skill on a given or average day (what does it look like?)

B) Knowing how much we can expect them to progress —which leads to your objectives OR the small increments of progress you can reasonably expect

EXAMPLE Lets go back to Andrew wanting to increase his

ability to cook independently from the SIS

His Goal Statement might be:

Andrew will plan and prepare a meal for family

and friends-specifically his mothers lasagne

recipe

Momma Mia’s Lasagne

1 1/2 lb. browned ground beef 1 lg. jar spaghetti sauce 1 1/2 c. water 16 oz. Mozzarella cheese Raw lasagna noodles (3 per layer) Alternate layers: sauce-noodles-cheese in 9 x 12 or 13 pan . Make 3-4 layers. Cover tightly with aluminum foil. Bake 45-60 minutes at 350 degrees.

Objectives - Examples Andrew will shop for the ingredients using his

mother’s lasagne recipe, given verbal instruction /assistance for caregiver on one trial.

Andrew will gather ingredients and necessary cooking utensils, given verbal instruction for 4 out of 5 trials.

Andrew will brown the beef and then drain it, given verbal instruction for 4 out of 5 consecutive trials.

Andrew will layer sauce-noodles-cheese until the pan is full, given verbal instruction for 4 out of 5 consecutive trials.

Andrew will put the lasagne in the pre-heated oven, set the timer for 55 minutes and cook until timer goes off, given verbal instruction for 4 out of 5 consecutive trials .

Objectives - Examples

With the assistance of staff as needed, Andrew will choose an activity in his community in which to participate 2 times per month for 3 consecutive months.

With the use of a picture schedule and no prompts, I will perform my daily self care routine in the morning (shower, brush my teeth and get dressed) prior to leaving for work for 4 weeks.

When asked by staff, I will verbally state one positive aspect of each community activity in which I engage 9 out of 10 consecutive times.

EXAMPLE Amy is also working on increasing cooking skills,

however her goal is to put a sandwich together.

Her shorter term objectives might be to…

A) gather the ingredients-bread, meat, cheese, condiment

B) to assemble the sandwich

C) To package it or to cut it in half

METHODOLOGY SUPPORTS

Andrew might have 1 to 2 hours of cls 2 to 3 days a week.

Amy may need ½ hour of cls 5 days a week if she is making her lunch for work or school

CONDITIONS-PART OF THE DIRECTIONS Andrew is his mother’s recipe card coupled with verbal

instruction (we might also use pictures of the various steps)

Amy is using a template made up of all of the ingredients for a sandwich for her first objective coupled with gestural prompts

METHODOLOGY CONTINUED CONDITIONS…

Where is the learning going to take place?

Real life situations or role playing or a

combination of both?

Social skills are great for role playing before a

social situation.

ID the female bathroom or

METHODOLOGY

ALWAYS TEACH STEPS IN THE SAME ORDER AND WITH THE SAME PROMPTS IF POSSIBLE.

Conditions &Measurability …. You can make behavior measurable by defining the

factors surrounding the behavior (conditions).

precipitating events, such as, "when asked to work

independently”

environmental factors, such as, "when dealing with female authority figures”

other patterns, such as "always after lunch," "in the community," “at his place of employment” When interacting with women in the community, Andrew

will maintain appropriate social space and will bring up topics appropriate to the persons present and the situation………

Supports

Natural Supports

Friends

Family

Neighbors

Co-workers

Volunteers

Peers

Church members

Community Supports Can be used by all, not

just those with disabilities

Other “system players”

Schools

Judicial System

Department of Human Services

LETS TALK ABOUT PARTICIPATION Think of it on a continuum from least to most and

define it for that individual

Independently With Gestural

Prompt

With verbal Intermittent

Prompt Physical

Assistance

Continuous Physical Assistance

Performance of a Specific Behavior

Measurable involves action

Observable-you can see

or hear it being done

Behavior

Measurable and Observable

Take

Perform

Complete

Use

List

State

NOT Measurable and Observable

Improve

Understand

Learn

(These can all be

interpreted differently)

LETS TALK ABOUT COMPLETION CRITERIA

How many times does the individual have to do

it?

Are you going for skill building ---competence

OR--Participation?

Imitation or initiation

Completion Criteria continued…

Definition of acceptable performance

Level of accuracy-100% correct?

Individualized for the person based on where they

are now

Duration for success (over what period of time

must the criteria be met?) day, week, month….

Making goals measurable You can also make it measurable by indicating a rate,

3 out of 4 times

80% of the time

5 minutes out of every 10

75% success

When using a rate, be sure you can specify and measure the "whole part." In other words, if you say an individual will do something 80% of the time, specify the time frame, i.e a 15-minute interval, for a week, for a month…..

Dead Man’s Test

If a dead man can do it, it is not an objective!

Could a dead man do the following? To reduce swearing by 90% over a 1 month period. To speak calmly to housemates without swearing

90% of the time over 3 consecutive months. To reduce incidents of stealing to 1 day or less per

month for 6 months. With staff verbal prompts, will calmly engage in

unfamiliar social events at least 4 times per month for 3 months.

Dead Man’s Test Avoid words like: reduce, stop, eliminate,

discontinue… these are all NON-ACTIONS.

AND also create an awareness or focus on what you don’t want, which ends up being all you see! Especially for interactional goals! Behavior plans!

FOCUS INSTEAD on what positive actions or WHAT YOU WANT TO SEE

LETS GO BACK TO ANDREW Andrew’s completion criteria might be

(OBJ A) Cook 3 meals over a 3-month period

given verbal instruction

(OBJ B) Cook 3 meals given just the initial verbal

prompt over a 3-month period

LETS REVISIT AMY… Amy might have the completion criteria to assemble her

sandwich given a gestural prompt for each step (item) 4

out of 5 consecutive trials, or 90% of the trials for one

month. (OBJ A,B,C…)

OBJ A Amy will gather two pieces of bread and place them

on her sandwich template given initial (1) gestural prompt

for 4 out of 5 consecutive trials (or 90% of the trials for 1

month)

METHODOLOGY Instructional style

Whole task or just one step at a time?

Buying a car or a house versus making lasagne?

You’re not going to mix the ingredients or brown the

hamburger and then throw them out..conversely you

probably won’t buy a car or a house the first time out!

INSTRUCTIONAL STYLE Generally, use the least amount of assistance needed for

successful completion

Use the fewest words possible for the training, reserve your

words for praise

Pair words with gestures

Use templates or pictures

ALWAYS do steps in the same order

TEMPLATES……

Sandwich Template

PICTURES

BARRIERS and SOUTIONS Some can be due to the differing abilities or

motivation of the learner and a good methodology

will address that..

HOWEVER much can be attributed to

CAREGIVER EDUCATION

CAREGIVER ATTITUDES

THE ENVIRONMENT

SPEAKING OF CAREGIVERS

Part of our job is to get caregivers to take

ownership

Get ideas from caregivers who know the

individual best

Start with special interests of the

caregivers

DATA COLLECTION Your data sheet and the data you collect needs to match your

completion criteria.

Calendar sheet

MONDAY/TASK TASK What Dan did How Long Shared Engagement initials

1

2

3

4

5

TUESDAY

1

2

3

4

5

WEDNESDAY

1

2

3

4

5

THURSDAY

1

2

3

4

5

FRIDAY

1

2

3

4

5

John Doe 12345

GOAL I will participate in 5 activities per day for at least 1 minute 50% of the days for a one month period. DATA COLLECTION: Document the task John participated in. What he did and how long and on how you were able to engage John-in a shared interaction, i.e a smile, a hand shake, a back rub, some indicator that John engaged with you personally during the task or at the end of the task.

Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Apply toothpaste

Brush front

top/bottom

outside of teeth

30 seconds

Brush front

top/bottom inside

teeth 30 seconds

Brush left side

outside

top/bottom teeth

30 seconds

Brush right

side outside

top/bottom

teeth 30

seconds

MONTH:

YEAR:

Date Int. Data Comments: Date Int. Data Comments:

1 17

2 18

3 19

4 20

5 21

6 22

7 23

8 24

9 25

10 26

11 27

12 28

13 29

14 30

15 31

16

DATA COLLECTION KEY

+ Objective independently completed as written on the first attempt following initial prompt.

- Objective not completed, completed on a later attempt, or assistance was required following initial prompt.

R Continued refusal.

X Not run. State reason in comments section.

Use Comments section for additional information to accurately describe effort.

Caregiver’s Signature Initials Caregiver’s Signature Initials

1. 3.

2. 4.

Data Sheets Make them simple Put the key on the data sheet

Documentation: I=Jane independently did this GP= required a gestural prompt, I,E pointing but nothing

said GI= required gestural instruction or several gestural prompts VP= required one verbal prompt VI= required more than one VP or verbal instruction IPA= intermittent physical assistance CPA = continuous physical assistance.

In-servicing, training and troubleshooting

Run through the goal with the caregivers who will be

teaching

Sometimes videos are helpful

If someone is not making progress, regroup re-think

and rewrite

Areas for Potential Goals

Meal preparation

Laundry

Activities of daily living

Shopping for food and other necessities of daily living

Areas for Potential Goals Money management

Socialization and relationship building

Leisure choice and participation in regular community

activities

Areas for Potential Goals

Non-medical care (not requiring medical

personnel)

Medication administration

Routine, seasonal and heavy household care

and maintenance