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Should Patients set SMART or MEANING(ful) Goals?

Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.

Does goal setting work?

A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.

How are goals set?

Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.

The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)

Specific, measurable, assignable, realistic, time bound
 
 

How should goals be set?

Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.

MEANING goal setting

 

While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:

  • The values and preferences of the patient
  • Clinical judgment of the healthcare professional
  • Time and resources required for the goal
  • Likely consequences of pursuing the goal

For Mr. Roberts, this approach would look like this:

value pluralism in goal setting

The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.

 

We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.

Posted in: Adherence, Behavior Change, Healthcare motivation, Healthcare transformation, Occupational Therapy, Rehabilitation Business

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Pushing, Pulling, Nudging and Tipping Healthcare Evidence Into Practice: Highlights from ACRM

We’re just back from 2 weeks on the road visiting Wellpepper customers and also attending the Annual Congress of Rehabilitation Medicine conference in Toronto where our research partners at Boston University presented the preliminary results from a study they’ve been working on. We’re so pleased and impressed with the results, but if you weren’t at the Congress, you’ll need to wait until November when we can share final results with you.

In the meantime, you can follow our recaps from some of the sessions we were fortunate to attend atIMG_0325 the conference. While the conference was heavily research-based (subtitled, “Progress in Rehabilitation Researchers), most researchers were affliated with teaching hospitals so that research could be put into practice. Also striking about this event, compared to many other healthcare conferences, is the team-based care and interdisciplinary nature of the presentations. Most presentations features care or research teams that included professionals with varying backgrounds including physicians, surgeons, dieticians, registered nurses, physical therapists, and occupational therapists. Another striking difference was that while everyone was striving toward repeatable outcomes, rehabilitation medicine requires a level of personalization that is specific to each patient’s ability.

Keynote: Pushing, Pulling, Nudging and Tipping Evidence Into Practice: Experience From the Frontline Implementing Best Practices in Rehabilitation

Dr. Mark Bayley from University Health Networks, and the University of Toronto kicked off the ACRM conference with a challenge to researchers to shorten the distance between research and implementation using techniques from other disciplines. His talk highlighted the challenges and provided solutions in a snappy and entertaining manner.

The Problem with Information Dissemination

To illustrate the problem, Dr. Bayley launched the talk by describing with the 386 year path from when Vasco da Gama observed scurvy in his ship’s crew to the implementation of vitamin C (or citrus juice in particular) as a protocol in the British navy. Although da Gama’s crew recovered from scurvy when given citrus fruit in India, the connection somehow was not made, and there’s a long history of sailors dying from scurvy, until the first ‘clinical trial’ when James Lind ran a 6-armed comparative study at sea and proved that citrus or vitamin C cured scurvy. Another 40 years passed before the British Navy adopted citrus as a standard.

Lest anyone in the audience start to feel smug about advances from scientific discovery to implementation today, Dr. Bayley revealed that it currently takes discoveries and new methods 17 years to get from research to implementation. He then spent the rest of the talk providing concrete suggestions that researchers could use to try to change this.

Researchers are often very focused on publishing, it’s how they are evaluated. However, publishing information and hoping that someone reviews it and sees the value is not enough to drive change into clinical practice. To put this into perspective, Dr. Bayley quizzed the audience on how many articles a healthcare professional would have to read each year to stay on top of all the research. The answer: 7300 or 20 articles each day. Compare this to the 1 hour of reading per week that most practicing healthcare professionals can manage, and you’ll see very clearly why best practices derived through research are often lost and not implemented. With only 1 hour per week for reading, is it any wonder most healthcare professionals get their information from their peers?

Barriers to Implementing New Methods from Research

As well, it’s not enough to provide recommendations but researchers must provide guidelines for how they should be implemented and understand the types of organizational barriers to implementation.

Barriers can include:

  • Individual perceptions
  • Complexity of solution
  • People who will need to adopt the new practice
  • Where the new practice will need to be implemented

Other things to consider are who will deliver the care, what stage of recovery the patient is in, the amount of time available with the patient, and the expected outcomes. Rehabilitation medicine adds an additional level of complexity to writing general implementation guidelines as each stage of recovery is different and requires it’s own care path, and the level of specificity for each is high.
Personal Barriers

When considering the people who will implement the guidelines from the research, many factors will impact their openness and ability to implement, including:

  • Knowledge: Does the person understand the research?
  • Skills: Does the research require the healthcare professional to learn new skills?
  • Social role: Does the healthcare professionals role within the healthcare system give them the authority or autonomy to implement the solution?
  • Beliefs: Do their beliefs in their capabilities or in the consequences of implementing the solution interfere with a successful outcome?
  • Motivation: Are they properly motivated or incentivized to implement the solution? For example, does the way they are compensated cause issues with implementation?
  • Emotion: Are their any emotional beliefs that will interfere with implementation, for example: “this is different than what I learned in school”?

Organizational Barriers

In addition to barriers that may arise through the people who are implementing research, there are many possible organizational barriers to implementation. These include:

  • Practice: How does the new method fit in with what is currently practiced?
  • Resources: Are the right people and skills available to implement?
  • Legal: Are their legal or regulatory issues that could block implementation?
  • Cost: Is it too expensive to implement? Are financial incentives aligned? (Of course the biggest issue here is always “Is it billable?”
  • Physical layout: Does the implementation require a change in the physical layout of the care center?
  • Time: Do staff have adequate time to understand the new procedure? Does the new procedure take longer than the time available?
  • Staff turnover: Can this new practice be maintained if staff change?
  • Equipment: Does it require new equipment to be purchased? Is it in the budget? Is it difficult to learn?
  • Communications: Does the practice require new ways of communicating between disciplines, within teams, and between patients and providers?

So should we give up?

To contrast the almost 400 years to recognize the treatment of scurvy, Dr. Bayley provided the example of how the use of general anesthetic spread thousands of miles from the UK to France and Germany in only a few months, and to widespread adoption within 2 years. Although the knowledge of properties of gases like either goes back further, the main adoption was relatively quick between demonstrations in 1844 and widespread adoption in 1846. The fast adoption stemmed from two factors: it was better for the patient and easier for the surgeon to operate on a patient that wasn’t squirming around.

What makes an invention or a new process sticky is that it’s good for providers and good for patients. (We would add to that in the US, it needs to be good for payers.)

Dr. Bayley then went on to provide some practical and possibly new advice for the best ways to effect change starting with things that don’t work within healthcare settings.

Methods that won’t effect change

  • Pamphlets
  • Total quality measures
  • Lectures

Methods that will effect some change

  • Patient driven or mediated
  • Conferences

Methods that will effect real change

  • Reminder systems (like hand washing)
  • Mass media for patients but will also impact providers
  • Financial incentives
  • Interdisciplinary collaboration

More practically, finding champions and interdisciplinary teams to implement changes, figuring out how the change relates to financial incentives, either the fear of losing money or the opportunity to gain money, and finding opinon leaders to publicize the changeDoctor-Recommeds-ProduceFinally Dr. Bayley introduced the theory of nudges and benevolent paternalism, or the idea that if you can make it easier for someone to do the desired behavior than the usual behavior they will. To illustrate this point, he showed a picture of an escalator and stairs, with an outline of a slim figure pointing to the stairs and a pudgy figure pointing to the escalator. Not quite as cheeky was a UK campaign that had pictures of local family physicians next to the fresh ruit and vegetable aisle asking people to eat more healthily which caused a 20% increase in produce sales.

This was a great talk to start the conference as it provided concrete advice for the presenters of all the great innovations over the next few days to get their advances into clinical practice in a period shorter than the current 17 years, because heaven knows our health system needs the nudge.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Rehabilitation Business

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