Goal Setting in Rehabilitation – State of the Art in German Rehabilitation and Research

Setting specific and individual rehabilitation goals is a key feature of qualified rehabilitation. It may fulfill several functions:

• the function of tuning goal issues and target values,

• the motivating function of clarifying and specifying the patient's objectives and concerns as well as planning implementation and anticipating barriers, which are crucial for self management in behavior change;

• the function of external quality assurance, that is the definition and tuning of goal issues and target values by experts and agencies.

Corresponding to the significance and multiple function of goal setting in rehabilitation, numerous quality requirements for goal setting have been discussed and investigated.

Goal setting should be addressed early in and continuously during the rehabilitation process. It should be documented in a concrete, understandable manner and goal achievement should be evaluated repeatedly, but at least at the end of rehabilitation. Finally, it should be transparent to the patient how rehabilitation goals relate to the treatment process (Glattacker et al., 2013; Vogel et al., 1994; Wade, 2009).

Goals should be formulated corresponding to the SMART-Rule, that is defining concrete goal states and measures for goal achievement, action plans and a time horizon of completion (the acronym SMART stands for specific, measurable, achievable, realistic/relevant and timed).

Involving the patient in goal setting and goal processing seems to be one of the major challenges. Goal setting should take into account the patient's illness beliefs and the expectations of rehabilitation as well as individual and social resources or barriers (Glattacker et al., 2013; Vogel et al., 1994). Several studies (Meyer et al., 2009) have shown that in daily routine there are considerable barriers to involve patients in goal setting. While experts often expect patients to name well defined goals, patients are not familiar with reflecting goals in an elaborative manner. They have to be prepared and guided through the process by a medical expert. Those often lack the communicative expertise, which is necessary to elicit, to develop and to discuss personal goals with patients.

Goal setting in rehabilitation has become an important issue of research in the last two decades. The German statutory pension insurance scheme as the largest agency of medical rehabilitation in Germany strongly promoted research on goal setting. In this contribution we will describe the current state of research and exemplarily focus on two approaches to enhance quality in goal setting in rehabilitation, which have been funded (beside others) by the German statutory pension insurance scheme.

The first approach is an intervention and training concept for medical experts (PARZIVAR). It focuses on patient involvement and incorporates the major quality demands on goal setting and goal processing throughout the rehabilitation process. The training manual includes guidelines for a goal dialogue about initial goals and goal achievement as well as facilities for documentation (Glattacker et al., 2013). The PARZIVAR intervention recently has been evaluated in a study showing that the training and implementation of the PARZIVAR procedure leads to superior distal and proximal rehabilitation results (Ullrich et al., submitted).

The second approach is a Handbook of Goal Setting in Rehabilitation, which is based on a survey of 1500 rehabilitation centers in Germany and an extensive review of literature. The rehabilitation centers were asked to fill out a questionnaire and to provide material, procedures or facilities. Materials were rated with regard to 36 quality dimensions, which before had been proposed and discussed by a scientific advisory board. The handbook contains a theoretical introduction and reasoning on the impact of goal setting in rehabilitation. It describes required action at different points in the rehabilitation process and depicts possibilities and solutions for implementation of a goal directed rehabilitation.

The handbook is available in a print version and an online version (url: www.reha-ziele.de). The online version additionally provides numerous materials which met the quality demands in question at the best. Among them are goal questionnaires, process models, forms for goal attainment scaling as well as guidelines for goal implementation and goal communication – with patients and within the rehabilitation team.

The potential of quality assurance in goal setting by the approaches reported is discussed in the light of evidence on goal setting and context factors in German rehabilitation centers.

References:

[1] Glattacker M, Dudeck A, Dibbelt S, Quatmann M, Greitemann B, Jäckel WH (2013). Evaluation einer Intervention zur partizipativen Vereinbarung von Rehabilitationszielen bei Patienten mit chronischen Rückenschmerzen. Die Rehabilitation, 52, 257 – 265.

[2] Meyer T, Pohontsch N, Raspe H (2009). Zielfestlegungen in der stationären somatischen Rehabilitation – die Herausforderung bleibt. Die Rehabilitation, 48, 3, 128 – 134.

[3] Vogel H, Tuschhoff T, Zillessen E (1994). Die Definition von Rehabilitationszielen als Herausforderung für die Qualitätssicherung. Deutsche Rentenversicherung 11, 751 – 764.

[4] Ullrich A, Mittag O, Garbrecht M, Dibbelt S, Glattacker M (submitted). Partizipative Zielvereinbarung in der Rehabilitation (ParZivar II): Evaluation einer Intervention bei Patienten mit chronischen Rückenschmerzen.

[5] Wade DT (2009). Goal setting in rehabilitation: an overview of what, why and how. Clin Rehabil 23, 291 – 295.