Put the person's goal where the team can see it

What we found in the news

NICE's quality standard on personalized goals in intermediate care (opens in a new tab), published in August 2018, gives us an established principle to revisit:

“Adults starting intermediate care discuss and agree personalised goals.”

— NICE, Quality statement 3: Personalised goals

Intermediate care includes time-limited support that helps people recover or become more independent. The standard emphasizes discussing goals with the person and reviewing them. It is a quality standard for services, not a new result showing that any particular digital care plan improves recovery.

Why this matters to us

A list might say that someone needs support with getting dressed, transport and a weekly activity. The person's reason for wanting that support may be much more specific: returning to a community choir they have missed.

That is an illustrative example, not a reported outcome. It shows why the purpose of a task can matter to the people carrying it out.

At genus, we are interested in care that leaves room for what a person values. A goal does not have to sound ambitious to deserve attention. Getting to a familiar group, preparing a favorite snack or managing part of a morning routine may be the thing around which someone wants to organize their effort.

Ask what the task is for

The team can begin by asking what the person would like to be able to do, continue doing or have more say over. Give them the communication support and time they need to answer.

The answer may not match the goal someone else would choose for them. That difference is worth discussing with respect. Professionals bring judgment about the available options and risks; the person brings knowledge of their own life.

For our choir example, the useful planning conversation might cover the route to the venue, the time needed to get ready and the person's preference about attending for part of a session. Clinical or rehabilitation decisions remain with the responsible professionals.

Avoid turning a broad hope into a promise. A team can discuss possible steps and uncertainties without guaranteeing an outcome. It can also recognize a worthwhile goal that needs a different service or support that is not currently available.

Help different roles understand their contribution

The person arranging transport does not need every detail of the clinical record. They may need to understand the agreed arrival time and any relevant assistance requirements. A support worker may need to know which part of getting ready the person wants to do independently.

The common purpose helps those separate tasks make sense, while appropriate information boundaries still apply.

An organization can review how its records present the goal. Is it visible to authorized staff doing the work? Is it expressed in words the person recognizes? Does the record distinguish what the person wants from what a professional has recommended?

If the goal changes, the old version should not quietly continue driving the schedule. Agree how the team will review it and where the current decision will be recorded.

Make progress a conversation

A completed task is useful information, but it may not answer whether the support is helping in the way the person hoped.

Someone might reach the choir and find the session too tiring. They might enjoy listening for a shorter period. Or their interest may have moved elsewhere. Those responses can inform the next conversation without being treated as failure.

Ask what worked, what felt difficult and what the person would like to try next. Where appropriate, include the supporters they choose. Keep changes within the agreed care plan and the authority of the staff involved.

Managers can learn from the practical obstacles that recur. If several people cannot reach an activity because the transport timetable does not fit, rewriting individual goals will not resolve the service gap. Bring that pattern into the relevant planning discussion.

The genus connection

Today, configured genus community tools include calendars, tasks and opportunities to record observations. Teams can use available workflows to keep agreed activities and relevant context together.

The organization still needs to decide how a person's goals are discussed, documented and reviewed. A completed calendar entry does not demonstrate rehabilitation progress, and a recorded preference does not replace a care assessment.

Our interest is in making the person's purpose easier to carry through ordinary arrangements. The useful question for any tool is whether it helps authorized people support the goal the person actually chose.

One question to take away

Could the person receiving support recognize their own purpose in the tasks your team has planned for this week?