Goal setting in Transition Care: Challenges and opportunities in clinical practice

Holly Campbell

1CHSALHN, Port Lincoln Health Services, PO Box 630, Port Lincoln, SA, 5606, holly.campbell@sa.gov.au

Background:

Transition from hospital to community is a critical time as it is imperative that clients are supported to regain function and independence. The Transition Care Programme helps to achieve this by providing short-term restorative care to eligible older people. This client-centered programme uses client goals to formulate care plans and inform service delivery. While the evidence for and the importance of goal setting is well documented, implementing this in clinical practice is a real life challenge. Challenges include variability in how goals are documented, reviewed and the way in which client progress toward goals is recorded.

Methods:

Based on best practice standards in goal setting, a clinical audit of all clients who completed a Transition Care episode over a period of three months in Country Health SA was conducted. Medical records, including the goal summary form, were audited using a customised audit tool. The purpose of the audit was to evaluate current practice against established best practice across rural health regions in South Australia.

Results:

Findings from the audit of approximately seventy medical records indicated variable compliance of client-centered goal setting practice. Challenges to client-centred goal setting included lack of awareness and knowledge, poor functionality of existing tools and competing priorities. As a result numerous opportunities to change practice, such as development of a goal setting guideline and targeted resources, have been identified.

Discussion:

Reducing variability and improving consistency in health care is critical. This initiative highlights important learnings about how to achieve consistent practice in client-centered goal setting.

Biography

Holly grew up on a farm on the Eyre Peninsula, South Australia where she returned to live and work after graduating from the University of South Australia in 2007. Since returning home, Holly has worked at Country Health SA as an Occupational Therapist, providing services to clients across acute and community health settings . Holly began working in the Transition Care Programme in 2009, where she found her passion for rehabilitation and restorative care. Holly now works as the Clinical Lead for Transition Care and is especially interested in rural health, service development, neurological and burns rehabilitation.