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His Goals, Not Ours

Start of Care · Episode 9

His Goals, Not Ours

Brian writes "independent walking" as the goal. Frank has a different one.

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Key takeawayPlan with the patientAsk the patient what matters to them and build the plan of care around their own goals. Turn their goal into measurable steps, and decide which disciplines they need, such as physical therapy, occupational therapy, an aide or a social worker. Discharge planning starts at the first visit: what will they need to manage safely without you?

In this scene

Brian: Goals: independent walking, safe transfers, medicine compliance. Done.

Carmen: Those are our goals. Did you ask Frank what he wants?

Brian: Frank, if this goes well, what do you want to be able to do again?

Watch the episode to see what happens next.

Questions to think about

  • Good goals in the plan of care come from:
  • Frank wants to walk to the mailbox. This goal is:
  • Discharge planning starts:

About this series

For home health nurses and therapists: the start-of-care in-home assessment. Timing, patient rights, homebound status, an accurate assessment, every medicine in the home, home safety, caregivers and emergency plans, screening, the patient's own goals, and closing the loop with the physician. Follow your agency's policies and the Medicare Conditions of Participation. See the whole series

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