Clinical Challenge
National Clinical Guidelines for Stroke 5^th edition (2016) highlights the importance of involving stroke patients (and family/carers where appropriate) in goal setting. Goals should be meaningful, challenging and of personal value. If goals are set in a step wise approach, and capture the aspirations of the patient they should help to motivate the patient and improve self-efficacy. A recent Clinical Effectiveness study day held by Derbyshire Community Health Services (DCHS) advocated the use of a health coaching model with patients to maximise patient involvement in rehabilitation.
 
SSNAP requires we record the date goals are first set with our patients and the percentage of goals the patient achieves during their time with ESSD. The SSNAP report does not capture the percentage of goals achieved and does not consider the quality or relevance of the goals set.
 
National Clinical Guidelines for Stroke 5^th edition (2016) identifies an ongoing lack of psychological care available to stroke patients across the stroke pathway. It calls for all members of stroke teams to support in the provision of psychological care as appropriate. Clinicians in DCHS follow a local mood pathway which again promotes the role that all clinicians can play in supporting patients psychologically.
 
The latest SSNAP report (Jan-June 2018) for our team identified 20% of patients required psychology during their time with our team and 0% of patients received it. This clearly highlights the need for the team to provide appropriate psychological support wherever possible. Meaningful goal setting that helps to motivate patients and improve their self-efficacy, clearly lends itself to all members of the ESSD team supporting patients with psychologically.
 
The Amber Valley and Erewash (AV/ERE) ESSD team accept stroke patients, for rehabilitation at home, for up to 6 weeks post acute hospital discharge. The team constitiutes physios, OTs, speech and language therapists, technical instructors and a nurse. The team identified that improving the goal setting process with patients could help to improve the psychological support we provide, improve patient motivation, self-efficacy and ultimately health outcomes.

Solution
Following the most recent SSNAP results (Jan-June 2018) the team reviewed the existing goal setting process. Goals were set for all patients but a number of inconsistencies in approach were identified;

• Some goals were discussed with the patient, hand written and left in the home. These goals may be recorded in patient notes but not consistently. Some of the handwritten goals were not fully legible.
• Some goals were discussed with the patient and then recorded in patient notes but the patient did not have a written copy of these goals.
• Goals were generally set by individual clinicians, specific to their profession. They generally included medical jargon and abbreviations.
• Goals were periodically discussed at MDT, but progress and changes were not consistently communicated with the patient. When reviewed at discharge many of the goals were found to be out dated or no longer appropriate.
• At discharge from ESSD patients regularly feedback they were not aware of their goals or did not understand the goals set.

Following the review the team identified ways in which they felt the goal setting process could be improved to fit with the National Clinical Guidelines for Stroke (2016) and the aims of DCHS. It was determined the team wanted patients to be actively involved in setting and reviewing their goals. They wanted to be aware of all the goals set with the patient, and how they would support the patient to achieve these.

The following actions were agreed and implemented;

•  Clinicians meeting the patient (and family/carers where appropriate) in the first week with ESSD to spend time talking to determine what was really important to them. Where appropriate, provisional goals based on their aspirations would be discussed.
• At weekly MDT meeting, the full team to review the aspirations of the patients and consider who and how these could be achieved. Where the aspirations are not realistic or achievable within the 6 week timescale, break down into component goals and identify relevant onward referrals.
• Goals set at MDT to be recorded on System 1 (electronic patient notes) and a copy printed off for the patient.
• The first clinician visiting the patient following MDT to discuss the printed goal sheet with the patient. The role of the patient (and family/carers where appropriate) and clinicians in achieving the goals to be discussed.
• The goals set to be reviewed and updated at weekly MDT meeting. A new goal sheet to be printed each week and discussed with the patient (and family/carers where appropriate) at the first visit following MDT.
• In final week with ESSD all goals to be reviewed with patient (and family/carers where appropriate).

Impact
The team are reviewing and developing the goal setting process on a regular basis using feedback from patients to help direct the process;
 
To date the following changes have been observed;

• More patients (and family/carers where appropriate) aware of their goals throughout their time with ESSD.
• Increased patient motivation towards achieving their goals.
• Increased self management. Patient (and family/carers where appropriate) more actively involved in completing home exercise programmes to support achieving their goals. This frees clinician time to progress with hands on therapy. It is proposed that this enables the patient to progress with therapy more quickly and achieve improved functional outcomes.
• Less dip in mood/increased anxiety levels in last week of ESSD as patient more aware of onward plan.
• Team members have reported increased job satisfaction as they work with more motivated patients.
• Team members are more aware of the patient’s goals, and their roles in supporting the patient to achieve these.
• Weekly MDT meetings are more cohesive as the team better understand to patient’s goals and their role in supporting the patient to achieve these.

Feedback
Aug 2018
You helped …. with everything he needed help with. His walking has progressed immensely. His speech and understanding has improved so much since he came out of hospital. The instructions on how to do things to help his recovery and I was involved.  Couldn’t have wished for anything better. Lovely people, caring. Worked with his every need and involved me and gave me info on how to do everyday tasks to make it easier for him. Showed me how to do exercises with him that would help with his mobility issues and speech. Thank you all for everything you have done to help… and myself over the last 6 weeks.
 
Oct 2018
All the carers were very professional and very well trained and knowledgeable about their role. Polite, very courteous. Work very well overall as a team with excellent communication skills.

The following brief case study demonstrates how the new goal setting process helped to motivate a patient to follow the necessary stages to ensure safe return to driving. It helped the patient to be more aware of the deficits caused by the stroke, and the implications of these on returning to driving. It has avoided the patient returning to driving when this would potentially pose a risk to himself and the public.
 
Patient X was seen by AV/ERE ESSD in Aug-Sept 2018. He presented with right sided weakness affecting his balance, ability to walk outdoors and fitness. He also presented with swallowing difficulties and slower process of information than prior to stroke.
 
Mr X was seen by all members of ESSD team. He was motivated towards his recovery and return to previous functional ability including walking outdoors, indoor bowling and driving. A number of goals were set with him and he worked with different team members to achieve these. He was motivated by achieving to goals and after 6 weeks was walking outdoors for up to half a mile and had returned to indoor bowling.
 
Initially Mr X proposed he would return to driving once he felt strong enough. He was unable to identify that he may have deficits from the stroke that would affect his ability to drive safely.
 
The team worked with Mr X to increase his awareness of the different elements required to return to driving safely. A goal was negotiated with him to understand the processes involved to return to driving safely.
 
This enabled the OT to complete necessary cognitive screening, and to assess processing skills to determine whether appropriate to progress to complete the Stroke Driver’s Screen (SDS). Although at this stage results suggested Mr X would not be able to complete the SDS, he was adamant he would be safe to return to driving. As Mr X had not achieved his goal of understanding the processes involved to return to driving safely the OT agreed to complete the SDS. When this was started Mr X became aware he was unable to complete the screen and he agreed to attend the Driving Centre for further assessment and advice.
 
This case study demonstrates how the ESSD team supported Mr X to understand and appreciate the stroke deficits that were affecting his ability to return to driving safely. He was supported to seek further assessment and advice to ensure that he achieves this goal.
 
In achieving the other goals set with ESSD Mr X remained motivated to work with the team, despite being uncertain of our advice and interventions at time.

Reflection
This project clearly shows how a review of the goal setting process used by AV/ERE ESSD has improved patient and clinician involvement in the patient journey. It demonstrates improved patient motivation and staff satisfaction. It is proposed this will improve functional outcomes for the patient.
 
The project will be ongoing. Based on patient feedback the team still need to avoid the use of medical jargon. The team are increasingly discussing the goals with the patient in more detail, and setting the goals with the patient using patient wording.
 
The team have invited a speaker from DCHS to explore the effective use of health coaching when goal setting with ESSD patients. It is hoped this will generate ideas for further improvement.
 
The team plan to collect individual patient case studies which demonstrate the effective use of goal setting with ESSD patients.
 
Team to consider relevant outcome measures to demonstrate the benefits of effective goal setting with ESSD patients.
 
Explore options for improving the goal setting with patients who present with cognitive and/or speech and language difficulties.

This case study was written by Amber Valley/Erewash ESSD. 


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