Person centred, Goal directed

Good attendant care

Good attendant care is:

Person centred:

Where you are at the centre of planning and delivery of services

Goal directed (to maximise independence):

During rehabilitation – focussed on achieving new goals
Life going on – focussed on maintaining goals (and preventing deterioration)

Enabling life in and with community:

Sees you as part of a social network which may include family, friends, neighbourhood & community.

Person centred

You are an equal partner in planning, developing and accessing services to appropriately  meet  their needs.

A person centred approach puts you and your family at the heart of all decisions.
It aims to:

• Be client focused,
• Promote independence and autonomy,
• Provide choice and control and
• Be based on a philosophy of collaboration and teamwork.

It takes into account your needs and views and builds relationships with family members.

Goal directed

Goals are what the client wants to achieve.

Rehabilitation programs exist so you can achieve your goals.

You also have goals post rehabilitation.

Attendant care, when required, is part of achieving you goals.

Workers are aware of the goals and see their work as contributing to you achieving your goals.

Enabling life in and with community

When focussing on you establishing your goals you are seen as part of a social network which may include your family, friends, neighbourhood & community.

Individual service plans

Clients have individual service plans worked out with their case managers and/or service providers. These individual service plans:

• Start with your goals
• Establish the steps needed to achieve the goals
• And then design the actions and services needed to achieve the steps.

Attendant care, when required, is part of the action plan for achieving the steps to achieve the goals.

What good attendant care looks like

• I treat my worker with respect and dignity
• I work on my goals to achieve my plan.
• Our work is goal directed work.
• We communicated well.
• We respect each other.
• We keep the relationship professional

 

Person centred

You are an equal partner in planning, developing and accessing services to appropriately  meet  your needs.

A person centred approach puts you and your family at the heart of all decisions. It aims to:

• Be client focused,
• Promote independence and autonomy,
• Provide choice and control and
• Be based on a philosophy of collaboration and teamwork.
• It takes into account your needs and views and builds relationships with your family members.

A person centred approach gives people:

• valued roles
• participation and belonging in the community
• freely given relationships
• greater authority over decisions about the way they live
• genuine partnership between the service, themselves and/or their family and allies
• individualised and personalised support arrangements.

Person-centred approaches require that organisations:

• have a committed leadership that actively instills the vision of a person-centred approach at all levels
• have a culture that is open to continual learning about how to implement a person-centred  approach
• consciously hold positive beliefs about people with a disability and their potential
• develop equal and ethical partnerships with people with a disability and their families
• work with people to individually meet each person’s needs so that they can be in valued roles in valued settings
• develop appropriate organisational structures and processes

Signs of a person centred approach

There are many signs of person centred approaches; and signs of approaches that are not person centred.  Some examples are:

Signs of a person centred approach 

• Making sure the person and their friends and family are central to identifying needs.
• Focussing on the future e.g. identifying that a person will need to cook in their own home.
• Asking the person what they should most like.
• Enabling people to have lots of experiences so they can make informed choices
• Thinking not only about choice, but also about how people can have more control over their own lives.
• Expecting that everyone is born into a common humanity and deserves a ‘good’ life
• Service providers recognise that the person/family has important knowledge about their own needs and about how these are best met.
• Supporting the person to have valued roles in the community

Signs of NOT being person centred

• Thinking about the person mainly in terms of what they cannot do.
• Focussing only on the present, e.g. identifying that a person must learn to cook.
• Telling a person what the decision is after it has been made.
• Expecting that people will immediately be able to make good decisions without support.
• Expecting that people with a disability cannot have lives like other people.
• Expecting that having a disability means having more in common with each other than with other citizens.
• Service providers holding all the power and controlling what happens to the person.
• Supporting the person only in the role of service client or other non-valued roles, fitting the person into activities and programs.

 

Goal directed

Goals

Goals are what the client wants to achieve.
Goals belong to you, not to workers, clinicians or service providers. 
Rehabilitation programs exist so that you can achieve your goals.  Rehabilitation goals typically focus on improvement.
Clients have life goals after rehabilitation – including maintain goals and prevent deterioration.
Attendant care, when required, is part of achieving your goals.

Benefits of setting goals

Setting client goals:

Helps you motivate yourself – i.e. it is easier to work towards achieving your goals when those goals are explicit and you are clear about what you are wanting to achieve.
Makes it clear to everyone what the you are wanting to achieve.
Makes it easier for everyone working with you to work together as a team and coordinate their efforts to achieving the goals.
Makes it easier for everyone to see how well things are working: Are the goals being achieved?

Individual service plans

Individual service plans are needed so that the steps needed to achieve the gaols are documented and everyone involved is working together.

Individual service plans:

• Start with your goals
• Establish the steps needed to achieve your goals
• And then design the actions and services needed to achieve the steps.

To be useful goals must describe what's to be achieved

Useful goals describe what the client wants to achieve, not what the client or service provider is supposed to do.  The program describes what is to be done.

Jill’s goal: To be able to care for her child independently.

Jill’s program: Jill does her home exercise  program and attends occupational therapy sessions. 

She does this because she wants to be able to care for her child independently.

Sometimes goals do not reflect what the client wants to achieve in their life. For example if Jill’s goal were written as: To do the home exercise  program each day and attends occupational therapy each week this would not be an appropriate goal, as it is focussing on what Jill has to do, not what she wants to achieve.

 

Useful goals

Setting goals is an art.
Useful goals have some of the following characteristics:
                                Specific
                                Measurable
                                Achievable
                                Relevant
                                Time-bound
Goals are more likely to be achieved when:
There are steps and an action plan that map out what has to be done to achieve the goal.
When the degree of achievement of the goals is monitored and the action plan is adjusted to better achieve the goal.

Specific

A goal is what the client is aiming for.

When a goal is specific the client knows what to aim for, when and how much.
For example, ‘John will join his friends on a fishing trip’ is specific, ‘John will increase his social interactions’ is not. 
For example “Beating your best time at walking” is specific where as “doing your best” is not.

“Measurable”

It must be possible to identify when the goal has been achieved (“measurable’). 

For example, these are “measurable” goals:

• Jill will return to work 20 hours per week over 4 days by end March 2014.
• Jack will host a dinner party including cooking a two course meal for himself and three friends at his home within 12 weeks.
• Karen will perform the family grocery shop every week.
• Jack will walk from home to the bus stop with a walking stick and stand-by assistance.

It is possible to know when these goals have been achieved.

These goals are not measurable (and therefore not useful goals):

• Jack will increase his contribution to family life.
• Jill will increase her community participation.

Achievable

Useful goals must be achievable goals.

Ideally, goals should be achievable but challenging. 

What is achievable for a  client will depend on many factors, e.g. the nature and impact of their injury, what they could do previously, their age, social situation, resources available and so on.
It is useful to think about shorter and longer time frames.  What is an achievable 3 to 6 month goal and what’s a goal in the longer term.

Relevant

Useful goals are relevant to the client.

When asked: ‘Is this goal something you want to work towards?’ or ‘Is this goal important to you?’, or ‘Does this goal matter to you?’   the client should answer “Yes”. 

If the client doesn’t answer “yes” the goal probably isn’t relevant to them or they are not seeing the connection between the goal and what they are really wanting to achieve.

Time-bound

Goals must be time-bound to be useful.

When will the goal be realistically achieved?  Without a time frame, there is less urgency to start taking action towards achieving the goal.  This is best specified by a date, rather than by a length of time e.g., ‘by February 2013’, rather than ‘in 3 months’ time’.

Action Plan

For goals to be useful for the client, goals need an action plan that maps the steps and actions needed to achieve the goal.

The action plan is driven by the goal.

Monitoring achievement

For goals to be useful for the client the degree of achievement needs to be regularly monitored and  the action plan modified if necessary.