Goal Planning

Most rehabilitation programs commence with setting of goals appropriate for that patient.

This is done in a multidisciplinary setting, so that each team co-ordinates the goals to be reached by the patient in a specified time frame. This provides the patient with an incentive to work towards the goal and also the satisfaction of achieving it and moving towards a higher target. Goal setting is carried out in discussion with the patient and members of the MDT and tailored to meet the demands of the individual patient. Goal-planning meetings are held at pre-determined periods of time. Such meetings also serve to monitor progress of the patient in the different disciplines of the MDT and adjust the goals according to progress, in consultation with the patient and team members. Goal setting also incorporates discharge planning, as the goals should be appropriate for the discharge destination. For example, a patient who is to be discharged home where access consists of steps leading to the front door and stairs within, will need to have goals set with the objective of managing stairs with safety after a specified period.

The patient is then introduced to the rehabilitation program and provided with a timetable setting out the activities for the week. Some centers appoint a member of the team, to act as a key worker for that patient, who will coordinate the activities of the program for that individual. The key worker will also identify other carers, including those who will be involved after discharge.

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