LTC Goals- Therapeutic or not?
Over the holiday week I filled in for a couple of local SNF's. I have to say, several of the patients I was scheduled to see had goals that were not what I consider therapeutic. I'm not sure if this comes from poorly trained OTs, or if these were generic goals that were set to keep the patient on caseload.
One patient with mild dementia (and other physical disabilities) had ADL goals. The patient's goal was to return home. As much as I doubt that this person will ever have the ability to return home, goals for working towards this patient's wishes should have been the focus of therapy. Increasing their independence with dressing skills was something that this person had little interest in, as they had assistance at home with these skills prior to being admitted to the SNF. This was documented in the person's OT evaluation, but for some reason it was included in their goals anyway. Upper body strengthening was another goal for this person. The main thing this person did at home during the day was watch TV. Sure, some activities such as transfers do require some strength for grasping, reach, etc, but the goal was to obtain a 4+/5 strength. I wonder why someone with a power wheelchair, a full time home aide, visiting nurses three times a week, and a very active family member would require that much strength.
Another patient seen had goals for W/C mobility. The goal was to be able to propel the chair 50 feet. As much as this person was physically capable of returning home, their plan included use of a rolling walker for mobility after discharge. In fact, the OT had paperwork in the chart to order the walker! This person told me that at home there was not enough room for a wheelchair. So why teach someone a skill that will never be utilized?
So, are the OTs of today graduating school with little knowledge of setting therapeutic goals? Or have we come to the point where company policies dictate the setting of goals?
To me a goal should be measurable, obtainable, and most importantly something the patient wants to address. A goal established just to have things to work on and keep the patient on caseload is unethical.
I want to believe that OTs have had a course in writing goals during their schooling. I know that coming up with specific and appropriate goals for a person is hard, especially with the time constraints today. On the other hand though, have you ever worked with an OT whose goals seem like they were rubber stamped? I mean every patient has the same goals, maybe with a different level of assist, but written the same way. Yes, these can be therapeutic and appropriate, but it sure gets boring to read.
If however, a company policy, whether written or unwritten, is used to develop goals then I'll be the first in line at the window to report fraud. Goals need to be determined by the evaluating therapist, not a book of rules. I unfortunately have run into this while working for one rehab company (now out of business, thankfully). As an unwritten policy, the company informed all their evaluating therapists that every Part A Medicare patient needed to be in a very high or ultra high category. Therapists were told to develop enough goals that would accomplish this. They were issued a laminated sheet of generic goals in order to assist them in writing up their evaluations. Needless to say many of these goals were not therapeutic, measurable or something the patient needed to address. A couple of the better OTs I worked with quickly placed these sheets in the round file container under their desk, thank goodness.
I guess I've always been a bit of a rebel when it comes to patient goals. I have always questioned the OT as to why a goal was written, more so when the patient refuses to work on it. Occurrences like this can only sour the person's attitude towards OT, and therapy in general. This is something we don't need happening in our profession.
Until next time, hope all your thoughts are good,
Tim