Using a recognised or formal planning framework can ensure a comprehensive person-centred planning approach and achieve meaningful and sustainable outcome.
A planning framework provides a structure to the process of planning. There are many planning frameworks available. Explore different frameworks to identify one or more that suit your service, team type, context and the person that you are working with.
Your personal style and the communication needs of the person will influence the approach chosen for those circumstances.
The different frameworks for goal setting and rehabilitation planning all follow a similar process.
Identify the goals
Whatever model for planning is selected, priorities, values and outcomes that are most important to the person need to be identified.
People may need support to find their goals initially. Ensure the person has the opportunity to think broadly about what is important to them and then begin to prioritise. This might include chatting about their pre-injury activities and life roles and their hopes for the future.
The ICF framework describes nine domains of activity and participation:
- Learning and applying knowledge
- General tasks and demands
- Communication
- Mobility
- Self care
- Domestic life
- Interpersonal interactions and relationships
- Major life areas
- Community, social and civic life
Understand and prompt consideration of goals across all these life areas to ensure a holistic approach to goal identification.
Jim's story – identifying the goal
Jim wants to help his wife with the shopping again. He wants to go to the supermarket with her and be able to push the trolley and pick items from the shelves by the end of three months.
Set the steps
Steps can be used to break the goal down into more measurable sub-goals or objectives.
Together, you and the person identify any impairments to achieving the identified goals.
This will, in turn, inform the steps required to achieve the goal.
Enablers may also be identified at this time, which can be used in agreeing on the actions in the next stage.
Jim's story – setting the steps
Impairments and activity limitations | Steps |
|---|---|
Poor static standing balance Unable to walk without assistance from one person | Be able to stand without assistance and reach to above shoulder height with one hand Be able to walk 100 meters using a wheeled walking frame |
Low mood and easily provoked to verbal aggression | Improve mood and ability to interact in social situations and therapy sessions for one hour with controlled behavioural responses |
Unclear speech | Able to communicate in conversations with family members and to ask simple questions of staff |
Reduced confidence and a fear that people will make assumptions about the nature of his physical presentation and capabilities | Jim and his family have a good understanding of his impairments Jim and his family have a range of strategies to manage interactions in public |
Some enablers in Jim’s scenario might be:
- Jim’s wife is supportive and encouraging
- Jim’s wife can drive and park close to the store entrance
- Jim was well known in his local community and people at his local shop know what has happened
- Jim's local grocery shop is small, so the walking distance inside is manageable
- Jim is really keen to be involved in shopping as he likes to buy his favourite biscuits
Negotiate the actions
Actions describe who will help work on those steps, and how it will be done.
Whenever possible, start with what the person themselves can do to work on the steps. This:
- reinforces their ownership of the goal and of the rehabilitation process
- lays the foundation for future self-management
- avoids a long-term dependence on therapies as the only means to achieve recovery or functional improvement.
Actions also identify the role and contribution of members of the therapy team, and where team members might be working towards a shared goal. Linking a therapist’s interventions to the person’s own goal can encourage motivation and compliance.
Jim's story – negotiating actions
There are likely to be several actions, given the range of impairments and activity limitations identified in the steps. Jim may work with a range of team members to achieve his goal. He may have a range of things he can do himself and things his family might do.
- Jim will make sure he is up and ready for the day by 9am every day.
- Jim will complete the home exercise program the physio has prescribed three times per day at home.
- Jim will attend the physio outpatient clinic twice a week to work on extending his safe walking distance with a walking frame.
- Jim and his wife will attend psychological counselling sessions once a week to develop strategies for his adjustment to his different abilities, promote positive coping skills and build their resilience.
- Jim’s wife will plan for shopping trips at times when the store is likely to be quiet.
- Jim and his wife will give Jim plenty of time to prepare himself for the trip.
- The social worker will help Jim apply for a disability parking permit.
Review the outcomes
Monitoring progress and reviewing outcomes is completed with the person. They can identify how they will know when they can perform the activity.
Celebrate achievement of incremental steps so people can track their progress towards a more aspirational goal.
Talk through steps that are not being achieved or are slower to be achieved. Invite the person to consider why and what changes they can make either to the actions or to their goals.
Jim's story – reviewing outcomes
Jim said he’ll feel like he’s important to their household when he helps his wife with the shopping.
In one scenario, Jim might have achieved physical capability to perform the shopping with his wife (and can therefore finish up with the physio), but might need to continue work on behaviour management, adjustment and managing difficult social situations.
Alternatively Jim might have achieved his goal, and now has a new goal to complete the shopping independently – including driving to the shops. So this outcome will be celebrated as well as leading to new steps and new actions.