Patient-Centered Goal Setting in a Hospital-Based Outpatient Stroke Rehabilitation Center

Transcription

1 PM R 9 (2017) Original ResearchdCME Patient-Centered Goal Setting in a Hospital-Based Outpatient Stroke Rehabilitation Center Danielle B. Rice, MSc, Amanda McIntyre, MSc, Magdalena Mirkowski, MSc, Shannon Janzen, MSc, Ricardo Viana, MD, Eileen Britt, MPT, Robert Teasell, MD Abstract Background: Goal-setting can have a positive impact on stroke recovery during rehabilitation. Patient participation in goal formulation can ensure that personally relevant goals are set, and can result in greater satisfaction with the rehabilitation experience, along with improved recovery of stroke deficits. This, however, not yet been studied in a stroke outpatient rehabilitation setting. Objective: To assess patient satisfaction of meeting self-selected goals during outpatient rehabilitation following a stroke. Design: Retrospective chart review. Setting: Stroke patients enrolled in a multidisciplinary outpatient rehabilitation program, who set at least 1 goal during rehabilitation. Participants: Patients recovering from a stroke received therapy through the outpatient rehabilitation program between January 2010 and December Methods: Upon admission and discharge from rehabilitation, patients rated their satisfaction with their ability to perform goals that they wanted to achieve. Researchers independently sorted and labeled recurrent themes of goals. Goals were further sorted into International Classification of Functioning, Disability and Health (ICF) categories. To compare the perception of patients goal satisfaction, repeated-measures analysis of variance was conducted across the 3 ICF goal categorizations. Main Outcome Measure: Goal satisfaction scores. Results: A total of 286 patients were included in the analysis. Patient goals concentrated on themes of improving hand function, mobility, and cognition. Goals were also sorted into ICF categories in which impairment-based and activity limitation based goals were predominant. Compared to activity-based and participation-based goals, patients with impairment-based goals perceived greater satisfaction with meeting their goals at admission and discharge (P <.001). Patient satisfaction in meeting their first-, second-, and third-listed goals each significantly improved by discharge from the rehabilitation program (P <.001). Conclusion: Within an outpatient stroke rehabilitation setting, patients set heterogeneous goals that were predominantly impairment based. Satisfaction in achieving goals significantly improved after receiving therapy. The type of goals that patients set were related to their goal satisfaction scores, with impairment-based goals being rated significantly higher than activity-based and participation-based goals. Level of Evidence: III Introduction Rehabilitation is a multidisciplinary process that involves assessing impairment, setting goals, implementing rehabilitation techniques, and evaluating progress [1]. As a central tenant of rehabilitation, goal setting occurs when a patient and health care professional collectively decide on the outcomes that they would like to achieve during the patients rehabilitation stay. These outcomes are dependent on how and when rehabilitation interventions are carried out [1,2]. In stroke rehabilitation, both formal approaches (eg, documentation and follow-up of patient goals that often involve patient-reported grading systems to measure improvement) and informal approaches (eg, verbal discussions between the therapist and patients to determine the focus of therapy) to goal setting are used [3] /$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation

2 D.B. Rice et al. / PM R 9 (2017) Previously, goal setting aligned with a biomedical model whereby decision making was often unilaterally driven by clinicians [4]; however, this approach often led to incongruent expectations between patients and clinicians. As a result, patients goals were often unmet [5]. Goal setting has since shifted toward a patientcentered model that ensures that the rehabilitation plan takes into account the patient s needs and expectations while still adhering to clinical standards [6]. This process of setting goals involves health professionals, patients, and their family or caregiver, as appropriate [7]. Patient participation in goal formulation has been shown to have beneficial effects, resulting in the development of personally relevant goals, as well as greater satisfaction with the rehabilitation experience overall [8]. Both the 2013 Canadian Best Practice Recommendations for Stroke Care [9] and the 2010 American Heart Association [10] recommend that goal setting and treatment planning poststroke incorporate aspects of the International Classification Functioning, Disability and Health (ICF) framework. The ICF framework considers the following 3 categories: impairments to body structure and function; levels of activity; and participation [11]. In a subacute stroke rehabilitation setting, Leach et al [3] found that goals set by therapists were primarily based on level of impairment and activity limitations. In contrast, therapists described patients as being focused on achieving participation-based goals, although this was not measured within this study. Patient centered goal setting can be challenging, as patients may have difficulty understanding their own diagnosis, level of impairment, and opportunity for recovery, which often contributes to idealistic goals. Furthermore, goals targeting participation have been found to be challenging to establish within an inpatient setting, as they often are outside the context of a hospital [3,12]. The benefits of goal setting have been consistently demonstrated in the literature. Stroke survivors who achieve their rehabilitation goals are less likely to be depressed, demonstrate stronger self-efficacy beliefs, and have more positive perceptions of their participation within the community [13]. Conversely, nonattainment of goals has been shown to have a negative impact on patients emotional well-being [14]. However, a patient s perception of attaining a goal can be a difficult construct to measure. The use of goal attainment measures has been criticized for involving potentially bias retrospective comparison of a patient s abilities before beginning rehabilitation. An alternative approach considers minimal clinically important differences in outcome measures administered during rehabilitation; however, this approach does not take into account what patients perceive to be a favorable outcome [15]. Because of these limitations, measuring patient satisfaction with the goals that they set during rehabilitation has been one method applied to serve as a benchmark for patient success [16]. Specifically, measuring patients satisfaction in their performance of specific goals both before beginning therapy and after therapy is a straightforward and realistic method of assessing patients perception of their own progress. This method of assessing a patients satisfaction with their abilities has been found to strongly correlate with patients goal achievement, and has been put forth as a measurement method that can inform the value of health care [16,17]. Gaining an understanding of the types of goals that outpatients who have experienced a stroke commonly set during rehabilitation can help to ensure that rehabilitation is adequately designed for patients needs, and that resources are appropriately available to help patients to achieve their goals. For example, understanding the goals that are commonly set by patients could ensure that appropriate therapists are available during outpatient rehabilitation. For clinical utility, we sought to gain both a focused understanding of the themes of goals and a broader conceptualization of patients goals through categorizing themes of patient s goals in the impairment-based, activity limitation and participation based ICF groupings. Leach et al [3] have previously studied goal-setting practices within these 3 ICF framework categories in a small sample of stroke therapists; however, this has not yet been studied in stroke patients themselves. Furthermore, considering patients satisfaction with their performance for specific goals that they set during rehabilitation has not been considered in an outpatient stroke sample. Therefore, our study sought to examine a large sample of patients with stroke deficits who were receiving hospital-based outpatient rehabilitation in an existing rehabilitation program. There were 3 objectives: to categorize the goals that patients wanted to achieve while in therapy; to classify patient goals within the ICF framework; and to compare patients satisfaction scores on admission and discharge between ICF categories of goals. Methods This study was a retrospective chart review of individuals attending an outpatient stroke rehabilitation program. Ethics approval was obtained from the University of Western Ontario Research Ethics Board. Rehabilitation Program and Dataset The Department of Quality Management and Clinical Decision Support provided the chart numbers of all patients who were referred for therapy to the Comprehensive Outpatient Rehabilitation Program (CORP), a hospital-based, time-limited outpatient rehabilitation program in southwestern Ontario, Canada. Patients can

3 858 Goal Setting in Stroke Outpatients be referred to CORP if they have experienced a stroke or other neurological condition (excluding spinal cord injury or acquired brain injury), although the program is predominantly accessed by individuals poststroke. Inclusion and Exclusion Criteria Patients were included in this study if they met the following 3 inclusion criteria: the patient was referred to CORP with a primary diagnosis of stroke; the patient was enrolled and attended at least 1 therapy session (ie, physiotherapy, occupational therapy, speech language therapy) between January 25, 2010, and December 31, 2013; and after the initial intake appointment, the patient set at least 1 goal during enrollment. Patients with aphasia who were unable to communicate their goals adequately were excluded from the study. In the case that patients were admitted and discharged to CORP more than once during the time period studied, data from only the first admissiondischarge session were collected and included in the analysis. Data Collection Demographic characteristics were extracted from each medical chart and included the following: age, gender, past medical history, type of stroke/diagnosis, stroke hemisphere, admission Functional Independence Measure (FIM) score, admission Montreal Cognitive Assessment (MoCA) scores, date of stroke onset, and dates of referral, intake, admission, and discharge to CORP. All patient goals were also extracted and entered into a database along with patient-reported satisfaction of performance toward each goal at admission and discharge. All data were extracted from the patients medical charts by 2 trained researchers (D.R., A.M.). Any discrepancies in data extraction were resolved by the 2 researchers referring to the chart to reach a consensus. All data were entered into a Statistical Package for the Social Sciences (SPSS version 23.0; SPSS Inc., Chicago, IL) database by a single researcher (D.R.) and checked for any inconsistencies by a second researcher (A.M.). Goal Setting Before beginning rehabilitation at CORP, patients attend an intake appointment that involves a general screen for eligibility (eg, determining whether patients have transportation to appointments) and completing preliminary assessments with a physiotherapist, occupational therapist, or speech/language pathologist to consider the severity of deficits. Therapy is not administered during the intake appointment. After the intake appointment during preliminary assessments, patients state the goals (up to a maximum of 10) that they want to achieve during therapy, and an occupational therapist or physiotherapist records these goals in the order that the patient states them, on a standardized form (Figure 1). For the purpose of analysis, patients goals are described as the first-, second-, and third-listed goals based on the order in which they were recorded on the standardized goal form. Within the existing program (CORP), all patients are asked to state their desired goals and/or outcomes of therapy. All goals are generated by the patient; however, during rehabilitation, if a therapist believes that a patient goal cannot be safely achieved during the time frame of rehabilitation, the therapist works collaboratively with the patient to break down the goal into smaller, more achievable components and then notes this on the goal satisfaction form. At the time of goal setting, patients rate their current satisfaction with their ability to perform each goal (Goal Satisfaction Score [GSS]) on an 11-point scale from 0 (not satisfied) to 10 (most satisfied). For example, if a patient s first goal is to increase their arm functioning, then they rate their current satisfaction with their arm functioning on admission. At the patient s discharge appointment, they re-rate their satisfaction for having met their goal in the performance recheck column (Figure 1); the performance review column, which can be completed when rehabilitation is approximately half-way done, was not completed. The GSS is administered in a standardized manner to all patients who receive therapy from CORP; it has not been validated, but was developed based on the Canadian Occupational Performance Measure (COPM) [18] by therapists on the CORP team for clinical use. A similar 10-point satisfaction scale has been used in patients attending rehabilitation for chronic spinal disorders [16]. Data Analysis All analyses were determined a priori unless otherwise specified, and were conducted using SPSS version 23.0 (SPSS Inc., Chicago, IL). For consistency in analyses and to maintain an adequate sample size, patients first-, second-, and third-listed goals were analyzed where available, unless otherwise specified. Descriptive analyses were performed to determine baseline and demographic characteristics of the sample. The frequency and mean number of patient goals reported were also calculated. To consider differences in patients who completed goal-setting measures versus those who did not, the groups were compared using independent t tests and c 2 tests of independence on demographic characteristics (age, gender, time since stroke, and FIM admission scores). All statistical tests were 2-sided with an a value of P <.05.

4 D.B. Rice et al. / PM R 9 (2017) Figure 1. Standardized goal-setting form. CORP ¼ Comprehensive Outpatient Rehabilitation Program. Patient Goals Objective 1: Recurrent Patient Goal Themes To consider the specific goals that patients set for outpatient therapy, 2 researchers (D.R., A.M.) independently categorized goals into themes and then sorted and labeled recurrent themes. To ensure that categorization of goals was consistent and agreed upon, a third researcher (S.J.) was consulted to examine the category labels. This approach has been previously used within a chronic stroke population [12]. Objective 2: ICF Classification Patient goals were further sorted into focused categories to compare goals for analysis according to ICF categories [11] (eg, level of impairment, activity

5 860 Goal Setting in Stroke Outpatients limitation, or participation restriction). To categorize goals, they were reviewed and sorted into the most appropriate of the 3 ICF categories being used. This method of categorization has been previously used with goal-setting data in a stroke rehabilitation setting [3]. Two researchers (D.R., A.M.) independently categorized goals into 1 of the 3 ICF categories by consulting the ICF checklist for the most appropriate of the 3 ICF categories, and any discrepancies were resolved through discussion. Post hoc, descriptive demographic data for patients first goals were presented separately for each ICF category and correlations between mean months since stroke and patients GSS. Objective 3: ICF Classification Satisfaction Score Comparison Furthermore, to compare the perception of patients goal satisfaction from when they set their goals to their discharge ratings, and across the 3 different ICF goal categorizations, a 23 repeated-measures analysis of variance was conducted. The 2 time points of GSS ratings were compared among the 3 different ICF goal categorizations for the first goal listed on the patient s GSS. Pairwise comparisons between ICF groups were conducted with Bonferonni adjustment. Before conducting analyses, we tested repeated-measures analysis of variance assumptions. Although there were adequate numbers of participants in each ICF group to compare between categories for the first-listed goals, this was not the case for the second and third goals. Therefore, paired sample t tests were conducted on patients second and third GSS by comparing scores at admission with scores at discharge for patients who completed the measure at both time points. Results Patient Characteristics A total of 471 patients received therapy through CORP from January 25, 2010, until December 31, Of these patients, 372 recorded at least 1 goal at admission and rated at least 1 of their goals with the GSS. After excluding patients who had not experienced a stroke (n ¼ 86), the final sample size included for analysis was 286 outpatients (Table 1). The majority of patients included were male (58%) and had experienced a left-hemispheric (40%) or right-hemispheric (39%) stroke. Most patients were referred to CORP for physiotherapy (79%) and/or occupational therapy (73%). Patients were referred for speech language therapy (24%) or social work (21%) less often. From the date of stroke onset, the mean number of months until the date of admission to CORP was 6.0 (standard deviation [SD] ¼ 15.5), with the number of months between onset and admission ranging from 1 to 45. The length of therapy from admission to discharge date was an average of Table 1 Demographic characteristics of patients (N ¼ 286) Characteristic Gender Male, n (%) 166 (58.0) Mean age, y (SD) 63.0 (13.6) Stroke side Left, n (%) 113 (39.5) Right, n (%) 110 (38.5) Bilateral, n (%) 19 (6.6) Not reported, n (%) 44 (15.4) Stroke type Ischemic, n (%) 190 (66.4) Hemorrhagic, n (%) 52 (18.2) Not reported, n (%) 44 (15.4) Mean time since stroke, mo (SD) 6.0 (15.5) Mean therapy duration, mo (SD) 3.6 (3.3) Mean FIM Admission (SD) (15.3) Mean MoCA (SD) 21.9 (5.3) MoCA ¼ Montreal Cognitive Assessment; FIM ¼ Functional Independence Measure. 3.6 months (SD ¼ 3.3 months), and ranged from 1 to 24 months, with 6 patients receiving therapy for between 12 and 24 months). The frequencies summed are greater than 100%, as many patients were referred for multiple services. The mean age of patients was 63.0 years (SD ¼ 13.6 years), with patients ranging in age from 16 to 95 years; 2 patients included were less than 18 years of age. The mean FIM admission scores of patients was (SD ¼ 15.3), with scores ranging from 51 to 126. Patients mean MoCA score on admission was 21.9 (SD ¼ 15.3), with scores ranging from 8 to 30. A comparison of demographic information based on c 2 and t tests between those included and excluded (nonstroke patients and patients who did not set any goals for rehabilitation) for analysis did not reveal a significant difference for age, gender, time since stroke, wait time between referral and intake date, or FIM admission scores (all P >.05) (Appendix 1). Patient Goals Objective 1: Recurrent Patient Goal Themes On average, patients set 3 goals (range ¼ 1-9). Patients first (n ¼ 286), second (n ¼ 267), and third (n ¼ 219) goals were categorized and sorted into recurrent themes (Table 2). Although there was notable heterogeneity between patient goals, they could be grouped into 16 themes, as follows: improve mobility, improve hand function, improve cognition, improve balance, increase strength, complete activities of daily living (ADLs), personal, improve arm function, increase range of motion (ROM), increase endurance, exercise, return to driving, improve speech, reduce pain, return to work, and improve vision. The personal theme included goals that could not be described uniformly (Table 2).

6 D.B. Rice et al. / PM R 9 (2017) Table 2 Patient goals categorized by themes Goal Theme Examples of Patient Goals Improve mobility To be able to walk without a walker Improve walking speed Improve hand function Increase use of left hand Improve skill in using right hand Improve cognition Improve memory Improve memory and cognitive strategies Improve balance Improve balance Improve balance when descending stairs Increase strength To improve left upper extremity strength Strengthen left upper body Improve strength in left hand Complete ADLs Toilet independently Improve ability to dress independently Personal Increase participation in meal participation To be able to shop in wheelchair for 3-4 items Engage in baking Be able to ride the bus Improve arm function Improve function of left arm Be able to use right arm more Increase ROM Improve left arm range of motion to reach items on table Increase shoulder range of motion Increase endurance Improve endurance Increase stamina Increase energy levels Exercise Review exercise program To be able to use the equipment offered in a fitness facility Have an exercise program developed for lower extremities Return to driving Return to driving Return to driving without spinner knob Improve speech To improve speech Learn strategies to assist with word finding Reduce pain Get up in the morning with a pain-free shoulder Pain control Reduce pain in right arm Return to work Return to work Would like to return to work with friends for 3-hour shifts Improve vision Improve vision Improve vision for reading Reduce left neglect and learn strategies to assist with vision problems ADLs ¼ Activities of Daily Living; ROM ¼ range of motion Despite the heterogeneity of patient goals, the most common goal listed first focused on improving hand function (21%), mobility (18%), and cognition (11%) (Table 3). Improving hand function and mobility were also the most prevalent second- and third-listed patient goals, followed by improving cognition and personal goals (Table 3). Objective 2: ICF Classification To further sort patients goals, we categorized first-, second-, and third-listed goals into the 3 ICF Table 3 Patients first-, second-, and third-listed goals (N ¼ 286) Categories of Patient Goals First Goal (N ¼ 286) n (%) Second Goal (n ¼ 267) n (%) Third Goal (n ¼ 219) n (%) Improve hand function 60 (21.0) 55 (20.5) 37 (16.9) Improve mobility 52 (18.2) 57 (21.3) 50 (22.8) Improve cognition 30 (10.5) 29 (10.8) 19 (8.7) Improve balance 28 (9.8) 24 (9.0) 22 (10.0) Increase strength 23 (8.0) 16 (6.0) 5 (2.3) Reduce pain 14 (4.9) 5 (1.9) 5 (2.3) Increase endurance 13 (4.5) 6 (2.2) 6 (2.7) Increase ROM 13 (4.5) 7 (2.6) 4 (1.8) Improve speech 12 (4.2) 6 (2.2) 11 (5.0) Return to driving 10 (3.5) 8 (3.0) 4 (1.8) Personal 10 (3.5) 18 (6.7) 34 (15.5) Improve arm function 9 (3.1) 10 (3.7) 4 (1.8) Exercise 6 (2.1) 7 (2.6) 3 (1.4) Complete ADLs 4 (1.4) 12 (4.5) 11 (5.0) Return to work 2 (0.7) 4 (1.5) 1 (0.5) Improve wision 0 (0.0) 4 (1.5) 3 (1.4) ADLs ¼ Activities of Daily Living; ROM ¼ range of motion. classifications; impairment-based goals were more common than those that were activity based or participation based. Specifically, 64.7% of patients first goals were impairment based, 28.7% were activity based, and 6.6% were participation based. Demographic data for each ICF group for patients first goal demonstrated that patients setting impairment-based goals were enrolled in therapy for the greatest length of time (mean ¼ 7.3 months, SD ¼ 18.9), and these patients also began rehabilitation with the lowest FIM admission score (mean ¼ 109.6, SD ¼ 13.7) (Appendix 2). For patients second goals, 52.4% were impairment based, 40.4% were activity based, and 2.7% were participation based. Similarly, patients third goals were predominantly impairment based (55.3%) or activity based (42.0%), and only a few were participation based (2.7%) (Table 4). Patients GSS were not significantly correlated with the mean number of months poststroke. Table 4 Examples and frequency of patients first-listed (n ¼ 286), secondlisted (n ¼ 267), and third-listed (n ¼ 219) goals categorized by ICF classifications ICF Categorization Examples First Goal Second Goal Third Goal Impairment 64.7% 52.4% 55.3% Improve upper body strength Improve balance Strengthen left upper body Activity limitation 28.7% 40.4% 42.0% Be able to write name Be able to use manual can opener Participation restriction 6.6% 7.1% 2.7% Return to work To be able to visit son s home for periods of time, possibly overnight ICF ¼ International Classification Functioning, Disability and Health.

7 862 Goal Setting in Stroke Outpatients Objective 3: ICF Classification Satisfaction Score Comparison To consider differences of improvement in patients GSS between ICF groups, we conducted a repeatedmeasures analysis of variance and found that there was no significant interaction between GSS admission and discharge scores and ICF classification (Wilks lambda ¼ 0.99, F2,194 ¼ 1.01, P ¼.37). However, for patients first-listed goals, their mean GSS scores improved significantly between admission and discharge (Wilks lambda ¼ 0.68, F1,194 ¼ 93.52, P <.001). Furthermore, significant differences were found between ICF categories in patients first reported goals based on their GSS (F2,194 ¼ 20.07, P <.001). Pairwise comparison revealed that patients who set impairmentbased goals rated their GSS significantly higher than both activity-based and participation-based goals at admission and discharge. In addition, patients with activity-based goals rated their GSS significantly higher than participation-based goals (Figure 2). Paired-sample t tests also revealed significant improvements in patient satisfaction scores on discharge for their second-listed (t182 ¼ 13.58, P <.001) and third-listed goals (t164 ¼ 13.86, P <.001]. Discussion The current study examined goal setting among a large cohort of individuals receiving time-limited, hospital-based outpatient stroke rehabilitation, to consider patient-centered goal setting within an existing program. The first objective was to evaluate the types of goals that individuals set. Despite the diverse types of goals made, the majority could be grouped into themes relating to improving hand function, mobility, and cognition. The second objective was to categorize goals according to the ICF classification system. For first-, second-, and third-listed goals, impairment-based goals were found to be the most common. Patients whose first-listed goal was impairment based were generally enrolled in therapy longer and were admitted with lower FIM scores than those setting activity-based or participation-based goals. The final objective was to compare patients GSS based on the ICF classification groupings, where patients were significantly more satisfied with their impairment-based goals on admission and discharge, in comparison to activity-based and participation-based goals. Patients whose goals were activity based also rated their GSS significantly higher on Figure 2. Repeated-measures analysis of variance for goal satisfaction scores. GSS ¼ Goal Satisfaction Score; ICF ¼ International Classification of Functioning, Disability and Health.

8 D.B. Rice et al. / PM R 9 (2017) admission and discharge than those with a participationbased goal. Patients top 3 GSS significantly improved when comparing scores from admission to discharge from the rehabilitation program. In considering patient goal themes, hand function was prevalent and the primary outcome that patients sought to improve, which is in line with previous research. Among stroke survivors, 55%-75% experience upper extremity impairments that often impede many basic (eg, washing) and instrumental (eg, shopping) ADLs [19]. The hand is the most dexterous limb of the body and is pivotal for its role in tasks that involve sensation and motor function [20]. Difficulties with mobility and cognition are also prevalent poststroke; for example, in a recent study [21], 83% of individuals at 3 months poststroke had a deficit in at least 1 cognitive domain. Impairments in hand function and cognition have been shown to reduce one s quality of life [20] and are predictive of one s ability to reintegrate into vocational and leisure settings [22]. Given that the patients included in this study were attending outpatient therapy and were therefore already living in the community, the prioritization of these goals is understandable. In a systematic review on patient goals, Rosewilliam et al [4] reported that clinicians often view recovery from the point of the stroke onward, whereas patients view recovery as the achievement of their pre-stroke status. In agreement with this perspective, when patient goals were categorized by the ICF system, they were primarily impairment based. Impairment-based goals aim to improve a problem with a body function that has experienced significant deviation or loss. Such examples may include overcoming impairment and achievement of ADLs and instrumental ADLs (eg, improving hand function). This finding in our sample of outpatients is consistent with findings reported by Leach et al [3] that among a sample of therapists working with subacute patients with stroke, rehabilitation goals were predominately representative of the impairment ICF classification. Leach et al [3] suggest that the narrowed focus on impairment may result from clinicians attempting to help patients create small stepping stones to recovery. Ultimately, these small goals may help patients to achieve their greater objective of increased independence [3]. Participation-based goals may be developed less often, as they are typically viewed as long-term objectives that require a longer amount of time and greater resources to achieve. These types of goals often require full autonomy (eg, return to work), making them more difficult to achieve during the time constraints of outpatient therapy. This could explain the significant difference found between GSS scores when making comparisons among the ICF groups (Figure 2). Patients were more satisfied with impairment-based goals at admission and discharge compared to activitybased and participation-based goals. It is important to consider that despite the drive toward patient-centered care, available resources and organizational priorities will ultimately lay the groundwork for any goal-setting approach [23]. The ability to achieve a health-related goal, particularly in a rehabilitation setting, is dependent on many factors. In this study, it was found that goals were extremely heterogeneous, but that the majority of patients perceived improvements and progress toward their goals. Given a patient-centered approach, a number of diverse goals seems reasonable, as each goal should reflect the unique needs of each individual as it relates to their personal recovery process. It may be possible to increase the proportion of individuals who achieve their goals by modifying or standardizing the goal-setting approach. For example, if a therapist believes that a goal cannot be safely attained, given a patient s current level of function and the time available in outpatient therapy, the goal could be broken down into smaller component tasks. If these smaller components are Smart, Measurable, Achievable, Realistic, and Timed (SMART), more patients may be able to be satisfied with the outcome of their goals, thereby positively affecting patients well-being. Because rehabilitation is a complex process that involves a multidisciplinary team, rarely, if ever, do therapists use a standard, single-treatment package [24]. A framework for the use of SMART goals in rehabilitation has been designed to accommodate the dynamic nature of this environment [25]. In a case study of an individual who had sustained a stroke, SMART goals served as a powerful tool for the patient s rehabilitation [26]. Based on previous research that highlighted barriers to implementing patientcentered goal setting [3], future studies could compare the use of SMART goals and therapist-led and patientcentered goal-setting approaches in a stroke rehabilitation setting. This could allow the various goal-setting approaches to be compared to determine the most appropriate goal-setting approach to implement in rehabilitation. This could also allow for comparing patient-reported satisfaction between patients who set unrealistic goals but had therapists intervene before beginning therapy, to patients who worked toward an unattainable goal throughout rehabilitation. It may be that if patients are informed that their goals may not be attainable before starting rehabilitation, the goal could be split into more feasible parts that the patient could worked toward achieving. Future studies should consider whether collaborating with a patient to provide a more realistic expectation of recovery has an impact on patient-reported satisfaction. Although the current study offers a number of novel findings, a retrospective research design has inherent limitations. Not all patients who received rehabilitation therapy set goals. Although there were no significant differences in demographic characteristics between the patients analyzed versus those who did not set goals, we cannot be certain that other systematic differences

9 864 Goal Setting in Stroke Outpatients between these 2 groups of patients were not present. Furthermore, based on the nature of this research occurring in an existing program, the measures within this study are limited to those applied by the rehabilitation program. In addition, although the administration of measures is to be standardized, not all measures used have been validated, such as the GSS. Moreover, because data collection was retrospective, we are not able to account for potential differences between therapists during documentation of goals, including the potential for misinterpretation of patient goals. Finally, goals were based on only 3 broad ICF categories; goals could be further sorted into more specific categories, as there are more than 1400 categories that are not mutually exclusive. Conclusion The current study examined patient-centered goal setting in an outpatient stroke rehabilitation setting. Within this setting, patients set heterogeneous goals that were predominantly impairment based. Patient satisfaction at meeting their goals significantly improved after receiving therapy. Impairment-based goals were rated significantly higher than activity-based and participation-based goals. These higher-rated impairment-based goals may represent a category of goals that are more realistically accomplished during the time constraints of outpatient rehabilitation. Ensuring that, even with patient-centered goal setting, patients have realistic expectations regarding achievements may be beneficial. The findings from this study can help to inform clinical care structures. Considering the types of goals that patients want to achieve can inform the allocation of resources and the proportion of therapists needed (eg, physical therapists, occupational therapists, and speech/language therapists) to better provide rehabilitation for common goals identified by patients. Acknowledgments The authors gratefully acknowledge Shannon Honsberger for providing feedback related to the goalsetting process within the Comprehensive Outpatient Rehabilitation Program (CORP). There was no specific funding for this study; however, we also gratefully acknowledge Allergan for providing an unrestricted educational grant, and the Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University. Supplementary Data Supplementary data associated with this article can be found in the online version at /j.pmrj References 1. Wade DT, de Jong BA. Recent advances in rehabilitation. BMJ 2000; 320: Wade DT. Goal setting in rehabilitation: An overview of what, why and how. Clin Rehabil 2009;23: Leach E, Cornwell P, Fleming J, Haines T. Patient centered goalsetting in a subacute rehabilitation setting. Disabil Rehabil 2010; 32: Rosewilliam S, Roskell CA, Pandyan AD. A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clin Rehabil 2011;25: Payton OD, Nelson CE, St Clair Hobbs M. Physical therapy patients perceptions of their relationships with health care professionals. Physiother Theory Pract 1998;4: Ozer MN, Payton OD, Nelson CE. Treatment Planning for Rehabilitation: A Patient-Centered Approach. New York: McGraw-Hill; Gage M. The Patient-Driven Interdisciplinary Care Plan. J Nurs Adm 1994;24: Holliday RC, Cano S, Freeman JA, Playford ED. Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit. J Neurol Neurosurg Psychiatry 2007;78: Dawson AS, Knox J, McClure A, Foley N, Teasell R, on behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group Stroke Rehabilitation. In: Lindsay MP, Gubitz G, Bayley M, Phillips S, eds. Canadian Best Practice Recommendations for Stroke Care (Update 2013). 4th ed. ca/wp-content/uploads/2013/07/sbp2013_stroke-rehabilitation- Update_July-10_FINAL.pdf. Accessed January 26, Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: A scientific statement from the American Heart Association. Stroke 2010;41: World Health Organisation. ICF: International Classification of Functioning, Disability and Health. Geneva: WHO; Lawler J, Dowswell G, Hearn J, Forster A, Young J. Recovering from stroke: A qualitative investigation of the role of goal setting in late stroke recovery. J Adv Nurs 1999;30: Brock K, Black S, Cotton S, Kennedy G, Wilson S, Sutton E. Goal achievement in the six months after inpatient rehabilitation for stroke. Disabil Rehabil 2009;31(11): Scobbie L, McLean D, Dixon D, Duncan E, Wyke S. Implementing a framework for goal setting in community based stroke rehabilitation: A process evaluation. BMC Health Serv Res 2013;13: Carragee EJ. The rise and fall of the minimum clinically important difference. Spine J 2010;10: Hazard RG, Spratt KF, McDonough CM, et al. Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: The impact of personal goal achievement on patient satisfaction. Spine J 2012;12: Smuck M. Commentary: More or less satisfied? Spine J 2012;12: Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: An outcome measure for occupational therapy. Can J Occup Ther 1990;57: Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors quality of life during subacute recovery. Stroke 2005;36: Hunter S, Crome P. Hand function and stroke. Rev Clin Gerontol 2002;12: Jokinen H, Melkas S, Ylikoski R, et al. Post-stroke cognitive impairment is common even after successful clinical recovery. Eur J Neurol 2015;22:

10 D.B. Rice et al. / PM R 9 (2017) Cumming TB, Brodtmann A, Darby D, Bernhardt J. The importance of cognition to quality of life after stroke. J Psychosom Res 2014: Lloyd A, Roberts AR, Freeman JA. Finding a balance in involving patients in goal setting early after stroke: A physiotherapy perspective. Physiother Res Int 2014;77: Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ 2008; 336: Bovend Eerdt TJH, Botell RE, Wade DT. Writing SMART rehabilitation goals and achieving goal attainment scaling: A practical guide. Clin Rehabil 2009;23: Rehman A, Berry J, Siddiqui MA. Post stroke rehabilitation based on SMART goals: A case study. J Exp Integr Med 2014;4: This journal-based CME activity is designated for 1.0 AMA PRA Category 1 Creditä and can be completed online at aapmr.org. This activity is FREE to AAPM&R members and available to nonmembers for a nominal fee. For assistance with claiming CME for this activity, please contact (847) Disclosure D.B.R. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, Parkwood Institute, Main Building Room B3025, 550 Wellington Road, N6C 0A7, London, ON, Canada. Address correspondence to: D.B.R.; danielle.rice@sjhc.london.on.ca A.M. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, Parkwood Institute, London, ON, Canada M.M. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, Parkwood Institute, London, ON, Canada S.J. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, Parkwood Institute, London, ON, Canada R.V. Department of Physical Medicine & Rehabilitation, St. Joseph s Health Care, Parkwood Institute, London, ON, Canada; Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada E.B. Department of Physical Medicine & Rehabilitation, St. Joseph s Health Care, Parkwood Institute, London, ON, Canada R.T. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, Parkwood Institute, London, ON, Canada; Department of Physical Medicine & Rehabilitation, St. Joseph s Health Care, Parkwood Institute, London, ON, Canada; Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada Disclosures outside this publication: grant, Allergan Inc (Educational Grant) Peer reviewers and all others who control content have no financial relationships to disclose. Submitted for publication April 18, 2016; accepted December 12, CME Question Most patients in the hospital-based outpatient stroke rehabilitation program desired improvement in which domain? a. Mobility. b. Hand function. c. Cognition. d. Balance. Answer online at me.aapmr.org