Goal Banking for Dysphagia Patients

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SLPs devise web-based platform to foster consistency between providers and from one facility to another.

Goal setting is a tried and true way for patients and therapists to define a path from problem to solution. The concept of setting goals is not new; in fact, it can be traced back to philosophical writings by Aristotle in 384-322 B.C.

In recent years, the Goal Setting Theory introduced by Edwin A. Locke, and further defined by Gary Latham, PhD, has produced the S.M.A.R.T. (Specific, Measurable, Assignable, Realistic, Time-related) objectives. In his work, Latham showed that clear goals and appropriate feedback provide motivation and, in turn, improve performance. Many speech pathologists have adapted Locke’s theory and incorporated Latham’s S.M.A.R.T. objectives into their practice as a means of establishing speech and language goals.

Goal Banking

Goal banking, on the other hand, is a relatively new concept. Goal banks can be found on sites throughout the web, allowing therapists to withdraw and/or make goal deposits. And with the advent of electronic medical records, goal banking has made the process of goal writing easier. Most educational settings have developed goal banks where therapists can copy from the bank and paste into their IEP. Major long-term care and medical records companies have stock or premade goals with checklists and/or “fill in the blank” properties in an effort to ensure that the established goals meet the requirements of their intermediaries. Medicare, for example, has specific guidelines as to the contents of an acceptable goal. Each must have a measureable timeframe and use terminology that reflects the clinician’s technical knowledge, indicating the rationale, type and complexity of activity, and report objective data showing progress toward each.
SEE ALSO: Patient-Centered Dysphagia Care

The process of putting together a goal with or without the availability of a goal bank remains challenging. Therapists have to identify the problem (or problems) and steps necessary to achieve each goal. In addition to specific content, intermediaries are requesting a “patient-centered” approach. And a plan of care that is evidence-based, integrating a treatment protocol vetted by research, is also required. To complicate matters, Medicare has developed incentive programs for healthcare providers called Accountable Care Organizations (ACO). The idea is to encourage healthcare providers to work together to treat an individual patient across care settings using a patient-centered focus to promote evidence-based medicine with patient engagement.

Goal Writing Issues

As our intermediaries rely on documentation as a means of assessing quality of care, measurement becomes difficult. Most facilities have a unique approach to goal writing based upon their electronic medical records program with a list of boxes or pull-down menus to choose from, making patient participation difficult and tracking progress across a continuum of care next to impossible. In an acute care setting, the dysphagic patient’s goal may read, “The patient will consume the least restrictive diet consistency meeting nutritional and hydration needs with a minimal risk of aspiration during his hospital stay.” This same patient at the extended care facility may have a goal that states, “The patient will tolerate thin liquids without s/s of aspiration during three consecutive sessions.” In the outpatient setting, “The patient will use the Supraglottic Swallow during intake of thin liquids 90% of the time with minimal cuing.”

How do we stop or at least reduce the constant changing and structure of goals from one setting to another and provider to the next? How can we incorporate the patient’s perspective in our goal writing throughout the course of treatment? How do we make goals that are comparable from facility to facility?

Consistency & Continuity

At Southwest Rehabilitation, we have a unique setting where patients are often seen throughout their rehabilitation process beginning in an acute care hospital, during extended care, in the home and eventually as an outpatient. We’ve devised a goal bank on our website for our therapists to draw from, allowing for consistency between providers and from one facility to another. We are able to cut and paste long and short-term goals, with pull-down menus that meet most of our patients’ needs. As a result, our therapists are able to track progress using a standard protocol from setting to setting throughout an episode of care – with huge benefits!

We can discern, given the use of the Dysphagia Patient Complaint Scale (DPCS), if the patient is seeing progress. The same problems are addressed from setting to setting and the approach or plan of care remains the same.

While this is not possible in most settings, it would benefit all providers if dysphagia goal banks were added to other organizations or entities, such as the American Speech-Language and Hearing Association (ASHA) and the National Foundation of Swallow Disorders (NFOSD). This would allow healthcare providers to work together to provide consistency in treatment of individual patients across care settings and quantify change in the patient’s functioning throughout an episode of care using a common language among patients with the same diagnosis.

As Medicare providers, we are asked to use Functional Outcome Measures, inserting G-codes during the billing process, which helps to quantify changes in the patient’s severity level throughout an episode of care. These codes, however, don’t address the problem, goal and plan. What if we had a common format with a specific set of evidence-based procedures to draw from, a list of typical problems expressed by dysphagic patients to use and measurement options found to be successful in measuring patient concerns?

Goal banks and their use in all settings will help speech therapists stop or reduce the constant changing of goals from one care provider and rehabilitation setting to the next. While individual providers can provide examples of goal banks in individual practices, it is ultimately a common goal bank repository from organizations, like ASHA and NFOSD, that we really need.

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About Author

Melody Sheldon, MS, CCC-SLP

Melody Sheldon is a speech-language pathologist and owner of a private practice in Coos Bay, Ore.

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