Goal setting is a vital process in care planning. It allows your care team (including external health providers like your doctor or pharmacist) to better understand your needs and preferences. It also offers an opportunity for positive reinforcement when goals are met or exceeded and a chance to review or change planned care goals. Goal setting also helps you and the people who care for you to understand the trade-offs involved in achieving your goals.
At Fleurenville, we take a structured approach to goal setting and organise goals according to five categories: medical care, physical quality of life, social-emotional quality of life, accessing services, and caregiver support. The relative importance of each category may change over time, as may the goals themselves. For this reason, regular case reviews are an essential part of care planning. Case reviews happen on admission, at least once each year after admission, on deterioration or improvement, and on request.
Often, non-medical goals are more important to people, which is why case reviews may include a diverse group of care professionals, including doctors, nurses, palliative specialists, physiotherapists, diversional therapists, psychologists, speech pathologists, personal carers, occupational therapists, dementia counselors, etc. Each professional brings their own perspective to the table, and sometimes one view may dominate the others.
To ensure you get the care that is right for you, it is crucial that everyone in the group understands your goals and keeps them at the centre of the care planning process.
Care is a learning process, not a problem-solving process. We are not here to cure; we are here to support you to achieve the highest possible quality of life, usually in the context of complex life-limiting conditions associated with older age. Yet, so often, the biggest challenge people face in aged care is not medical or clinical; it is simple loneliness, boredom, or helplessness.
Setting aside a professional perspective to understand what is important can be challenging. If you are medically trained, you may tend to see the disease instead of the person, and you may not understand or value the perspective of non-medical professions. For example, suppose your goals include socialising, mobility, and independence. In that case, you may wish to minimise or avoid medication or transfers to the hospital. Still, your team will not be in the best position to support you if they do not understand what matters most to you.
Fleurenville is underpinned by philosophies including human rights, ageing-in-place, and person-centred-care. Our care is delivered in the context of relationships, including relationships between you and us, between your family and us, and between you and your family. It is a care partnership, and your role is to help us learn what matters to you and how those things change over time. We aim to support you in achieving your goals and living how you choose, within the constraints we all face in our lives every day.
I encourage everyone to consider their care and whether it aligns with their needs, goals, and preferences. If your care is not aligned with your goals or your goals have changed, simply request a case review to provide our team with the opportunity to learn about what is important to you.
Jan Heystek
CEOFleurenville Aged Care
