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Abstract Background An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown. Methods The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3–5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index – Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units. Discussion This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial’s findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD. Trial registration ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Background: Goal setting is done in collaboration with the patient, but patient-identified (PID) goals are not always addressed. The purpose of this study was to determine reasons PID goals are not set in low-vision rehabilitation and for which tasks. Methods: Occupational therapists completed an individualized survey to determine from 15 probable reasons why they did not set a PID for specific tasks. Results and Conclusion: PID goals were not set for 3 activities of daily living, 13 instrumental activities of daily living, 4 social participation, and 10 leisure tasks. Further research is needed to understand how prioritization of PID goals differs between therapists and patients. [ABSTRACT FROM AUTHOR]

Background: An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown., Methods: The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units., Discussion: This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD., Trial Registration: ClinicalTrials.gov NCT04538157. Registered on 3 September 2020., (© 2023. The Author(s).)

Date Presented 04/20/2023 Research is needed on goal setting for patient-identified goals and areas of occupation prioritized. Goals by five therapists were not set if 'not attainable or are unrealistic.' Goals were least likely set for instrumental activities of daily living, followed by leisure, and then basic activities of daily living. The most goals were set for social participation. Primary Author and Speaker: Theresa M. Smith [ABSTRACT FROM AUTHOR]

Janne Evensen,1 Helene Lundgaard Soberg,2,3 Unni Sveen,2,3 Knut A Hestad,4,5 Berit Arnesveen Bronken4 1Department of Physical Medicine and Rehabilitation, Innlandet Hospital Trust, Gjøvik, Norway; 2Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway; 3Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 4Department of Health and Nursing Sciences, Faculty of Health- and Social Sciences, The Inland Norway University of Applied Sciences, Elverum, Norway; 5Department of Research, Innlandet Hospital Trust, Brumunddal, NorwayCorrespondence: Janne EvensenDepartment of Physical Medicine and Rehabilitation, Innlandet Hospital Trust, Gjøvik 2819, NorwayTel +47 61 11 75 00Email janne.evensen@sykehuset-innlandet.noAim: The primary aim of this study was to investigate the applicability of the Patient-Specific Functional Scale (PSFS) in patients with acquired brain injury (ABI) admitted to a specialized rehabilitation unit in a regional hospital. A secondary aim was to identify patient characteristics and functioning that predicted changes in the PSFS.Patients and Methods: In a cohort study, 59 patients with ABI were assessed for the ability to complete the PSFS. A trained multidisciplinary team applied the PSFS as part of a collaborative development of rehabilitation goals. The modified Rankin Scale (mRS), the Functional Ambulation Categories (FAC), the Rivermead Behavioural Memory Test (RBMT), the Norwegian Basic Aphasia Assessment (NBAA) and the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) were used to identify characteristics of the sample. Multivariate regression analyses were performed to investigate associations between changes in the PSFS score from admission to discharge and a selected set of participant baseline characteristics and functioning.Results: Fifty-four patients (92%) of the patients with ABI were able to complete the PSFS. The five (8%) who were unable to complete the PSFS had severe cognitive or language impairment. The PSFS score improved by a mean of 2.6 (SD 2.0) points from admission to discharge. The LOTCA score made the strongest unique contribution to explain the change in the PSFS score (beta = 0.477, p= 0.020).Conclusion: In the present study, most patients with ABI (92%) were able to complete the PSFS. Cognitive function on admission was a predictor of improved functioning on the PSFS.Keywords: multidisciplinary rehabilitation, patient-specific outcome measure, patient-identified goals, shared decision making

Goal-oriented care is an approach to care delivery that uses patient-identified goals to drive care planning. Implementing goal-oriented care requires team members to cognitively shift the focus from "what is the matter" to "what matters to patients," and align their mental models of what it means to care for patients. Yet, no empirical studies of goal-oriented care apply evidence from the cognitive sciences, such as Shared Mental Model (SMM) theory. We conducted a qualitative case study of an interprofessional team that adopted goal-oriented care in Vermont, US (n = 18). Guided by SMM theory, we distinguished between task-related and team-related mental models. We used framework analysis and qualitative content analysis to determine mental model content and similarity. The most shared content areas were operationalizing goal-oriented care, engaging in formal and informal communication, taking a "whole-person" approach, taking a team approach, and building trusting relationships with patients and with other team members. Trust was the only construct that spanned both task and team mental model categories, highlighting the importance of both intra-team trust and provider-patient trust to the implementation of goal-oriented care. Team members developed SMMs through training, regular meetings, and interactions during care delivery. This study provides insight into the cognitive mechanisms that underlie team-based goal-oriented care delivery, which can be used to inform implementation, training content, and future research. [ABSTRACT FROM AUTHOR]

I Recommendations i : Define the ideal model of perioperative care, and identify relevant performance criteria with evidence-based, best practice protocols, pathways and models of care for the entire patient journey. Surgery is an essential aspect of health care, required for approximately one-third of the global disease burden, and is projected to increase substantially over the coming decades.1-3 Disturbingly, it is not without risk; approximately one in five patients suffers major post-operative complications,4 and death within 30 days of surgery is the third leading cause of death worldwide (a hidden pandemic).5 Risks to patients, and healthcare budgets, are estimated to increase three-fold out to 2047 because of an ageing population and increasing burden of co-morbid disease.6 To address this "hidden pandemic", we need proactive strategies to generate higher value care, improve patient outcomes and reduce healthcare expenditure. Funding models to enable: Integrated care, appropriate SDM which incorporates risk discussions (with multidisciplinary teams for some risk groups), patient-identified goals and appropriate value-based advance care plans and intervention ceilings. [Extracted from the article]

Improving care for older people with end-stage kidney disease (ESKD) requires the adaptation of standards to meet their needs. This may be complex due to their heterogeneity in terms of multimorbidity, frailty, cognitive decline and healthcare priorities. As benefits and risks are uncertain for these persons, choosing an appropriate treatment is a daily challenge for nephrologists. In this narrative review, we aimed to describe the issues associated with healthcare for older people, with a specific focus on decision-making processes; apply these concepts to the context of ESKD; identify components and modalities of shared decision-making and suggest means to improve care pathways. To this end, we propose a geronto-nephrology dynamic, described here as the necessary collaboration between these specialties. Underscoring gaps in the current evidence in this field led us to suggest priority research orientations. [ABSTRACT FROM AUTHOR]

Purpose:We investigated stroke rehabilitation clinician’s perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement. Methods:Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams). Results:There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’). Conclusions:Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.Implications for rehabilitationGoal setting is often promoted as a relatively simple, straightforward way to structure interactions with patientsPatient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitationClinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics [ABSTRACT FROM PUBLISHER]

Introduction The GOAL Cluster Randomised Controlled Trial (NCT04538157) is now underway, investigating the impact of comprehensive geriatric assessment (CGA) for frail older people with chronic kidney disease (CKD). The primary outcome is the attainment of patient-identified goals at 3 months, assessed using the goal attainment scaling process. The protocol requires a dedicated process evaluation that will occur alongside the main trial, to investigate issues of implementation, mechanisms of impact and contextual factors that may influence intervention success. This process evaluation will offer novel insights into how and why CGA might be beneficial for frail older adults with CKD and provide guidance when considering how to implement this complex intervention into clinical practice.Methods and analysis This process evaluation protocol follows guidance from the Medical Research Council and published guidance specific for the evaluation of cluster-randomised trials. A mixed methodological approach will be taken using data collected as part of the main trial and data collected specifically for the process evaluation. Recruitment and process data will include site feasibility surveys, screening logs and site issues registers from all sites, and minutes of meetings with intervention and control sites. Redacted CGA letters will be analysed both descriptively and qualitatively. Approximately 60 semistructured interviews will be analysed with a qualitative approach using a reflexive thematic analysis, with both inductive and deductive approaches underpinned by an interpretivist perspective. Qualitative analyses will be reported according to the Consolidated criteria for Reporting Qualitative research guidelines. The Standards for Quality Improvement Reporting Excellence guidelines will also be followed.Ethics and dissemination Ethics approval has been granted through Metro South Human Research Ethics Committee (HREC/2020/QMS/62883). Dissemination will occur through peer-reviewed journals and feedback to trial participants will be facilitated through the central coordinating centre.Trial registration number NCT04538157.

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II-IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included 'patient-centred care', 'quality of life' and 'shared decision making'. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations. [ABSTRACT FROM AUTHOR]

Objective: Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers.Methods: Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers.Results: HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security.Conclusion: Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers.Practice Implications: Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population. [ABSTRACT FROM AUTHOR]

INTRODUCTION: People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs. METHODS: A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group. RESULTS: Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined. DISCUSSION: Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants. CONCLUSION: By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes. [ABSTRACT FROM AUTHOR]

Background: Goals generated by Goal Attainment Scaling (GAS) can be used as an outcome measure to promote person-centred research and care. There are no training packages which support its use outside of the rehabilitation discipline. This paper describes the development and evaluation of a training package to support the implementation of GAS as an outcome measure in healthcare research. The training package consisted of classroom teaching, a training manual for self-directed learning, one-on-one simulation and hot reviews. It was developed for the GOAL Trial, a randomised controlled trial assessing a Comprehensive Geriatric Assessment's effectiveness in enabling frail older people living with chronic kidney disease to attain their goals. Training participants were invited to complete pre- and post-training online evaluation surveys. Results: Forty-two healthcare professionals attended an initial online classroom teaching, with 27 proceeding to administer GAS to GOAL Trial patients. Response rates for the online pre- and post-training surveys were 95% and 72%, respectively. Prior to training, only 15% of participants reported being able to appropriately scale and troubleshoot GAS goals. Post-training this was 92%. There was 100% participant satisfaction for the training manual, one-on-one simulation, and hot reviews. Conclusions: This training package helps ensure healthcare professionals administering GAS have adequate knowledge and skills. It has the potential for adoption as a guide to support the implementation of GAS by other researchers seeking to embrace persont-centred principles in their work. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to determine the feasibility of low-load resistance training with blood flow restriction (BFR) for people with advanced disability due to multiple sclerosis (MS). Methods In this prospective cohort study, 14 participants with MS (Expanded Disability Status Scale [EDSS] score = 6.0 to 7.0; mean age = 55.4 [SD = 6.2] years; 71% women) were asked to perform 3 lower extremity resistance exercises (leg press, calf press, and hip abduction) bilaterally twice weekly for 8 weeks using BFR. Feasibility criteria were as follows: enrollment of 20 participants, ≥80% retention and adherence, ≥90% satisfaction, and no serious adverse events related to the intervention. Other outcomes included knee extensor, ankle plantar flexor, and hip abductor muscle strength, 30-Second Sit-to-Stand Test, Berg Balance Scale, Timed 25-Foot Walk Test, 12-Item MS Walking Scale, Modified Fatigue Impact Scale, Patient-Specific Functional Scale, and daily step count. Results Sixteen participants consented, and 14 completed the intervention, with 93% adherence overall. All participants were satisfied with the intervention. A minor hip muscle strain was the only intervention-related adverse event. There were muscle strength improvements on the more-involved (16%–28%) and less-involved (12%–19%) sides. There were also changes in the 30-Second Sit-to-Stand Test (1.9 repetitions; 95% CI = 1.0 to 2.8), Berg Balance Scale (5.3 points; 95% CI = 3.2 to 7.4), Timed 25-Foot Walk Test (−3.3 seconds; 95% CI = −7.9 to 1.3), Modified Fatigue Impact Scale (−8.8 points; 95% CI = −16.5 to −1.1), 12-Item MS Walking Scale (−3.6 points; 95% CI = −11.5 to 4.4), Patient-Specific Functional Scale (2.9 points; 95% CI = 1.9 to 3.8), and daily step count (333 steps; 95% CI = −191 to 857). Conclusion Low-load resistance training using BFR in people with MS and EDSS scores of 6.0 to 7.0 appears feasible, and subsequent investigation into its efficacy is warranted. Impact Although efficacy data are needed, combining BFR with low-load resistance training may be a viable alternative for people who have MS and who do not tolerate conventional moderate- to high-intensity training because of more severe symptoms, such as fatigue and weakness. Lay Summary Low-load strength training with BFR was feasible in people who have advanced disability due to MS. Using BFR may provide an alternative for people with MS who do not tolerate higher intensity training due to more severe symptoms, such as fatigue and weakness. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The Self-Assessment Goal Achievement (SAGA) questionnaire is a patient-completed instrument designed to assess goal attainment in the behavioral or pharmacologic treatment of lower urinary tract symptoms (LUTS), including overactive bladder (OAB). The SAGA questionnaire allows patients to identify and rank the importance of treatment goals before treatment is initiated; the follow-up SAGA questionnaire quantifies the achievement of these patient-identified goals. The objective of this qualitative research was to confirm the content validity of the German, Spanish, Swedish, and English (UK) language versions of the SAGA questionnaire in patients with OAB with or without other LUTS. Methods: The SAGA questionnaire was translated to each language in accordance with a well-established forward and backward harmonization method. Patient interviews were then conducted according to a cognitive debriefing methodology. Qualitative analysis of patients' input allowed assessment of content validity of each linguistically adapted SAGA questionnaire. Results: All patients ( n = 29; six to eight per targeted country) found the SAGA questionnaire easy to understand and to complete. Most patients completed the nine prespecified (fixed) treatment goals and were able to add up to five personal goals in the open-ended portion and rate each goal by importance. Differences were identified in how the various languages communicated some of the concepts assessed with the SAGA questionnaire. Rewording of the translated versions of the questionnaire was necessary in some cases. Conclusions: This linguistic content validation study in four European languages indicates that SAGA is a comprehensive, easy-to-understand, and relevant questionnaire for patient-completed evaluation of LUTS/OAB symptoms and treatment goal attainment. [ABSTRACT FROM AUTHOR]

Aims: The first aim of this study was to measure the extent of care planning and support for health goals within a sample of Māori/non-Māori people with long-term conditions (LTCs). The second aim was to compare those with and without care plans, and those with and without support for health goals, with respect to health and experiences with general practice. Background: Collaborative care planning, resulting in a written care plan, and providing support for patient-identified goals are important aspects of LTC management. In the MidCentral District Health Board region, primary care practitioners have had help to achieve this through the introduction of comprehensive assessment and care-planning tools. Methods: 569 people with at least one LTC, who had recently enrolled in a local EnhancedCare+ programme or were receiving care from an LTC community clinical nurse, were recruited into the region's "Talking about Health" study, designed to explore LTC care from patient and provider perspectives. Consenting participants chose to complete a paper (by post) or electronic (email link) questionnaire, which included measures of health, healthy behaviours, experiences with doctors and nurses in general practice, patient activation, care planning/goal support and demographics. Results: People with written care plans were more active self-managers, reported better interactions with primary-care doctors and nurses, and perceived receiving more support from the general practice team than those without. Results were similar for people receiving support for their health goals, but differences in mental and physical health were also evident. More Māori than non-Māori reported having a written care plan, and support for health goals in the absence of a written care plan. A slightly broader range of benefits was evident for non-Māori than Māori, but the different sample sizes need to be taken into account when drawing conclusions. Conclusions: Written care plans and practitioner support for health goals appear to benefit people with LTCs. Support for health goals is important as, even without a written care plan, it was associated with better health and more positive ratings of practitioner interactions. Challenges for the region are to involve more people/whanau in collaborative care planning and to address system-wide barriers to embedding care-planning practices into routine care. [ABSTRACT FROM AUTHOR]

The objective of this article is to introduce the GO-FAST Tool (developed by the Toxnet group) to clinicians working in the field of neurological rehabilitation, specifically post-stroke spasticity management. The concepts utilized in the Tool and described in this article can be broadly grouped into five topics: the principles of patient-centred goal-setting; an algorithm for setting SMART (specific, measurable, attainable, realistic, and timed) treatment goals; goal-related target muscles and botulinum toxin type A dose determinants; goal attainment follow-up, scoring, and interpretation; and the multimodal approach to spasticity management. The Tool can enhance clinical practice by providing guided assistance with goal-setting and target muscle selection for botulinum toxin type A treatment. It also provides support with the follow-up evaluation of goal attainment and calculation of treatment success. The Tool is designed to be used by clinicians with varying levels of expertise in the field of neurological rehabilitation and post-stroke spasticity management, from those who are new to the field to those with many years of experience. A case study is presented in the Results Section of the article to illustrate the utility of the Tool in setting SMART treatment goals in the management of patients with post-stroke spasticity. [ABSTRACT FROM AUTHOR]

Background: Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).Patients and Methods: Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.Results: Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.Conclusion: ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.Trial Registration: The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.Plain Language Summary: Older people need support when they are discharged from the Emergency Department (ED) to their home as a visit to the ED is linked to negative outcomes. This study reports on a trial to reduce negative outcomes in older people discharged from the ED by an assessment in the ED and treatment in the home. Twenty-nine patients attending the ED of University Hospital Limerick were randomly assigned to three groups as follows: One group got the normal care and treatment; Group two received a comprehensive assessment by a dedicated geriatric doctor in the ED and were referred to other health professionals as needed; a third group, called ED PLUS, also received a comprehensive assessment by a dedicated geriatric doctor in the ED and an additional six-week treatment program led by a physiotherapist. The physiotherapist visited the older adult in their own home within twenty-four hours of discharge to start treatment based on what the older adult needed to do to live safely in their own home and again at week four and week six. The same geriatric doctor who saw the older adult in the ED telephoned the older adult in week two to check medications and discussed the case with the physiotherapist. A dietitian and occupational therapist telephoned the older adults to check nutritional intake and if any aids were needed in the home. All older adults in the ED PLUS group had improved quality of their life, improved mobility and did not need to go back to the hospital or ED at six weeks and six months unlike the two other groups. The COVID-19 pandemic affected recruitment, but all ED PLUS patients were extremely satisfied. [ABSTRACT FROM AUTHOR]

Aim: Educational attainment is consistently highly valued by young people with mental ill health, yet maintenance and completion of education is a challenge. This paper reports on the implementation of a supported education programme for youth mental health., Methods: Between 10 October 2019 and 10 October 2020, a supported education programme was delivered within primary and tertiary youth mental health services. A description of the programme, context, and adjustments required due to COVID-19 is presented, and the educational outcomes of young people referred to the programme were explored. Two case studies are also presented., Results: The programme received 71 referrals over this period, of which 70.4% had not yet completed secondary school and 68% were experiencing multiple mental health conditions. Overall outcomes were positive, with 47.5% of the 40 young people who chose to engage with the programme maintaining or re-engaging with education. However, the remainder of those who engaged withdrew from the programme, often reporting challenges due to COVID-19 such as social isolation or increased uncertainty. Additionally, a number of young people declined or disengaged from the programme to focus on employment., Conclusion: This report of the experience of integrating a supported employment programme in Australian youth mental health services reinforces the need for such support, and provides preliminary evidence for its successful implementation as part of routine care. The disengagement in response to COVID-19 highlights the real-world challenges of the pandemic, while young people's voicing of employment goals indicates the need for combined educational and vocational support-to assist transition and progression between these goals., (© 2024 The Authors. Early Intervention in Psychiatry published by John Wiley & Sons Australia, Ltd.)

Background: Care coordination is central in models of integrated care. Goal-oriented care is one approach that supports care coordination for multimorbid and complex patients by tailoring shared care plans to patient-identified goals rather than disease-specific targets. However, providers struggle with the adoption of goal-oriented care. Personal values have been found to influence provider behaviour in care delivery. It is possible that personal values may be a mechanism to drive the adoption of goal-oriented care. This work aims to understand the personal values of providers in the adoption of goal-oriented care. Methods: This is a sub-study of an international comparative case study of three primary healthcare sites that have implemented goal-oriented care in Ghent (Belgium), Ottawa, (Canada), and Vermont, (United States). A secondary analysis of 17 semi-structured interviews from the Vermont case site was conducted using inductive thematic analysis. The Vermont case study is situated within an integrated care setting. At this site, providers come from various disciplines and work in collaboration across organizations. Findings: Preliminary findings demonstrated that providers delivering goal-oriented care valued 'putting the patient at the centre', providing care in a holistic manner to understand the 'whole person', which could best be supported through team-based care. These values were often linked to beliefs around the importance of addressing the social determinants of health to improve health outcomes of patients. While most providers shared these values, they told different stories regarding how they came to these beliefs, which related to their education and training experiences. Community-based providers including social workers and mental health providers were introduced to the concepts of social determinants early in their professional training and reported personcentredness to be a core value of their profession. Alternatively, physicians and providers trained in medical models reported a shift in their values from problem-oriented towards personcentredness. Specific team-based training supported the adoption of core values like personcentredness. Discussion: Despite differences in disciplines and organizations, participants demonstrated similar values. These perceived difference in values appear to trace back to the model of training in postsecondary education that providers were trained under. However, with additional training on goal oriented care, shifts in values appear to be possible as participants were aligned in the values they held that support goal-oriented care. Another value that supported the adoption was a belief in team-based care for their patients. In practice, this was reinforced by working with interdisciplinary teams and an increasing presence of integration in their work environment. Conclusion: Across different disciplines and organizations, participants strongly valued personcenteredness, understanding the whole person, and team-based care. There is an opportunity to utilize structured training in goal-oriented care for providers to have aligned values to support its adoption. Lessons learned: Common values among interdisciplinary teams seem to support the adoption of goal-oriented care. Structured training in goal-oriented care appears to lead to providers having common values. Future research: The analysis will expand to other case study sites to compare and contrast the provider values working in other primary healthcare settings in different contexts. [ABSTRACT FROM AUTHOR]

Objective Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral–based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral–based hybrid telerehabilitation intervention for Latino patients with chronic spine pain. Methods A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses. Impact This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain. [ABSTRACT FROM AUTHOR]

Aim: Individual Placement and Support (IPS), an evidence‐based supported employment model developed for adults with serious mental illness, has been recently targeted to young adults with mental health conditions, but little is known about its adoption in this age group in the United States. Methods: We recruited a volunteer sample of nine IPS programmes in five states serving young adults with mental health conditions aged 16 to 24. IPS team leaders reported programme and participant characteristics and rated barriers to employment and education. Results: Most IPS programmes were located in community mental health centres, served a small number of young adults, and received most referrals from external sources. The study sample of 111 participants included 53% female, 47% under 21 years old, 60% diagnosed with a depressive disorder; 92% had an employment goal, and 40% had an education goal. IPS specialists reported that managing mental health symptoms was the most common barrier to achieving employment and education goals. Conclusion: Future research should examine how IPS programmes could best provide services to young adults. [ABSTRACT FROM AUTHOR]

Background: Discontinuation of antipsychotic medication may be linked to high risk of relapse, hospitalization and mortality. This study investigated the use and discontinuation of antipsychotics in individuals with first-episode schizophrenia in relation to cohabitation, living with children, employment, hospital admission and death. Methods: Danish registers were used to establish a nationwide cohort of individuals ⩾18 years with schizophrenia included at the time of diagnosis in1995–2013. Exposure was antipsychotic medication calculated using defined daily dose and redeemed prescriptions year 2–5. Outcomes year 5–6 were analysed using binary logistic, negative binomial and Cox proportional hazard regression. Results: Among 21 351, 9.3% took antipsychotics continuously year 2–5, 38.6% took no antipsychotics, 3.4% sustained discontinuation and 48.7% discontinued and resumed treatment. At follow-up year 6, living with children or employment was significantly higher in individuals with sustained discontinuation (OR 1.98, 95% CI 1.53–2.56 and OR 2.60, 95% CI 1.91–3.54), non-sustained discontinuation (OR 1.25, 95% CI 1.05–1.48 and 2.04, 95% CI 1.64–2.53) and no antipsychotics (OR 2.00, 95% CI 1.69–2.38 and 5.64, 95% CI 4.56–6.97) compared to continuous users. Individuals with non-sustained discontinuation had more psychiatric hospital admissions (IRR 1.27, 95% CI 1.10–1.47) and longer admissions (IRR 1.68, 95% CI 1.30–2.16) year 5–6 compared to continuous users. Mortality during year 5–6 did not differ between groups. Conclusion: Most individuals with first-episode schizophrenia discontinued or took no antipsychotics the first years after diagnosis and had better functional outcomes. Non-sustained discontinuers had more, and longer admissions compared to continuous users. However, associations found could be either cause or effect. [ABSTRACT FROM AUTHOR]

New efforts have begun to transform healthcare to focus on patient‐centered care. Such efforts will be facilitated by eliciting, operationalizing, and measuring the attainment of patient‐identified goals of healthcare. This article describes a practical approach to goal setting and measurement that can be used in efforts to implement patient‐centered care. [ABSTRACT FROM AUTHOR]

Background: An expanding base of evidence indicates that chronic gastrointestinal disorders not only impact physical wellbeing, but also affect many psychosocial aspects of life. However, less is known about gastrointestinal motility disorders. The present study aimed to explore how individuals experience gastrointestinal motility disorders and their impact on daily living. Methods: Eleven people with a gastrointestinal motility disorder participated in semi‐structured interviews face‐to‐face or via telephone. The interviews explored how participants came to be diagnosed, their experiences with health professionals, as well as the impact of dysmotility on enjoyment of food, socialising, eating out and quality of life (QoL). Interviews were tape‐recorded, transcribed and analysed using an inductive thematic analysis approach. Results: Analysis revealed an overarching theme of frustration that stemmed from three subthemes: (1) feeling misunderstood, judged and dismissed by health professionals leading to delayed diagnosis, misdiagnosis and multiple diagnoses; (2) severity and unpredictability of undesirable gastrointestinal symptoms; and (3) reduced QoL because of physical and social limitations, impairing their ability to have normal life experiences, including education, work and social activities. Conclusions: Dysmotility is a complex illness that impacts almost all aspects of a person's life. In addition to managing reported physical symptoms, the social and psychological burden associated with dysmotility needs to be addressed to improve outcomes and QoL. Key points: This research indicates that current healthcare systems are inadequate for supporting people suffering from severe dysmotility.Delayed diagnosis and misdiagnosis lead to feelings of mistrust in the healthcare system, poorly managed symptom control and reduced quality of life for this patient group.A comprehensive multidisciplinary model of care for the management of dysmotility is needed to ensure that people suffering dysmotility are provided with the best‐practice care. [ABSTRACT FROM AUTHOR]

Objective This study investigated the validity, reliability, responsiveness, and interpretability of the Patient-Specific Functional Scale (PSFS) in subacute stroke rehabilitation to determine its suitability to measure patient-identified rehabilitation goals. Methods A prospective observational study was designed according to the checklist from Consensus-Based Standards for Selecting Health Measurement Instruments. Seventy-one patients diagnosed with stroke were recruited in the subacute phase from a rehabilitation unit in Norway. The International Classification of Functioning, Disability and Health was used to assess the content validity. Assessment of construct validity was based on hypotheses for correlation of the PSFS and comparator measurements. We assessed reliability by calculating the Intraclass Correlation Coefficient (ICC) (3.1) and the standard error of measurement. The assessment of responsiveness was based on hypotheses for the correlation of change scores between the PSFS and the comparator measurements. A receiver operating characteristic analysis was conducted to assess responsiveness. The smallest detectable change and minimal important change were calculated. Results Eighty percent of the PSFS items were classified as activities and participation in the International Classification of Functioning, Disability and Health, indicating satisfactory content validity. The reliability was satisfactory with an ICC of 0.81 (95% CI = 0.69–0.89). The standard error of measurement was 0.70 point, and the smallest detectable change was 1.94 points. Five of 7 hypotheses were confirmed for construct validity, and 5 of 6 were confirmed for responsiveness, indicating moderate construct validity and high responsiveness. Assessing responsiveness with a criterion approach resulted in an area under the curve of 0.74. A ceiling effect was identified for 25% of the participants 3 months after discharge. The minimal important change was estimated to be 1.58 points. Conclusion This study demonstrates satisfactory measurement properties for the PSFS in individuals undergoing inpatient stroke rehabilitation. Impact This study supports the use of the PSFS to document and monitor patient-identified rehabilitation goals in patients receiving subacute stroke rehabilitation when applied using a shared decision approach. [ABSTRACT FROM AUTHOR]

While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are "aging ready." Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity. [ABSTRACT FROM AUTHOR]

Introduction: Public and private funders have a mutual interest in effective chronic disease management at the primary care level due to its potential to reduce hospital admissions. The challenge lies in the complexity of the funding sources in Australia. The government's Medicare system funds general practice on a fee for service basis, Primary Health Networks (PHNs) are government funded organisations commissioning care within local communities while private health insurers (PHIs) fund hospital care and are not permitted to insure GP services. Change implementation: Sonic Clinical Services (SCS), the primary care division of Sonic Healthcare, has implemented a model of chronic disease management that incorporates a pooled funding approach by private and public funders. SCS has partnered with PHNs and PHIs in a collaborative approach to resource primary care in a way that complements the Medicare fee for service structure. Aim of change: The WellNet Integrated Care Program is a suite of GP-led programs providing targeted and coordinated chronic disease management delivered through a Patient Centred Medical Home model which aims to shift the way patients are managed in primary care. The Medical Home approach shifts the epicentre of health care delivery from the clinician to the patient through a redesign of infrastructure, health care team roles and modes of delivering care. Developed by SCS, its unique elements include: Risk stratification according to level of risk and complexity Voluntary patient enrolments cdmNet, a web-based platform enabling care planning in real time across the entire clinical team Dedicated nurse care coordinator Change management support Stepped care approach Data analytics. Target population: There are 5 programs targeting 4 population groups: FeelWell & GetWell - complex multi-morbidity BeWell - multiple morbidities StayWell - uncomplicated chronic disease LiveWell - at risk of chronic disease. Highlights: SCS has partnered with Sydney North PHN and 4 PHIs to fund the BeWell program through 5 general practices in NSW. In Victoria, SCS has partnered with Australian Health Service Alliance, a service company representing a number of small to medium size PHIs, to deliver the program through 6 general practices. The start dates for these practices have been staggered with the earliest centre commencing enrolments in February 2017. The early results have included demonstrated improvement in care coordination, patient engagement and achievement of patient identified goals. Conclusion & discussion: The timeline for the program is 12 months with a formal independent evaluation undertaken at the conclusion of the pilot study. This funding model is sustainable as it is designed around the MBS funding system with affordable investment by PHNs and PHIs. The model is transferable to other partnerships who share the will to properly fund chronic disease management. Lessons: Lessons were learned around addressing different PHIs needs and expectations and finding consensus in the approach. Having a fully developed WellNet program with detailed workflows, costings and change management processes has proved to be the key to getting all the stakeholders on board. [ABSTRACT FROM AUTHOR]

To describe, in a naturalistic setting, the impact of the early use of LAI-AP on functional outcomes of early psychosis patients as compared to oral antipsychotics (OAP). Longitudinal prospective 3-year naturalistic study of all consecutive admissions (n = 416) to two Early intervention services (EIS) for psychosis comparing baseline characteristics and the evolution of global functioning, occupation (work and studies), and living arrangements autonomy according to the route of administration of the antipsychotic medication. The cohort was divided into four groups: LAI-AP first (started on LAI-AP and later received OAP), OAP first, LAI-AP only, and OAP only. Global assessment of functioning (GAF) improved in all groups, but our mixed-effect model did not show any significant association between the route of administration and the GAF outcome. The LAI-AP only group was significantly less likely to have extreme residential instability at 3 years than the other groups despite its highest proportion of homeless youth and their poor prognostic factors at baseline. Our naturalistic study suggests a significant protective effect of LAI-AP on extreme residential instability for the most vulnerable patients, but no impact of the first AP administration route on other functional outcomes was observed at 3 years of follow-up. Long-acting injectable antipsychotics seem promising to avoid extreme residential instability in early psychosis. Global assessment of functioning (GAF) improved in all groups. There was no significant association between the first route of administration and global functionning. [ABSTRACT FROM AUTHOR]

It is suggested that goals are hierarchically organised, with goals at the highest level representing fundamental values and motivations. These abstract goals are said to have a series of sub-goals which represent a means of reaching higher-level goals. While a number of studies have explored goals in the context of psychosis, little is known about idiographic goal generation processes in those experiencing psychosis. Using a Behaviour Sequence Analysis approach, the aim of the current study was to assess the feasibility of the goal task for use with individuals experiencing psychosis. A total of 73 adults receiving care from UK rehabilitation services completed a goal task designed to elicit higher-level goals. Results indicated that the goal task may be a feasible tool to support those experiencing psychosis to generate lower- and higher-level goals. The goal task utilised in the current study may therefore be a valuable goal generation tool for use by clinicians. [ABSTRACT FROM AUTHOR]

Individualized and interdisciplinary rehabilitation programs are recommended following a mild traumatic brain injury (mTBI), but often have long waitlists. Accordingly, innovative evidence-based programs are needed. The first objective of this study was to determine the number and types of rehabilitation goals chosen by individuals completing an interdisciplinary outpatient rehabilitation intervention (BrainEx90) for persisting symptoms following an mTBI. The second objective was to investigate whether completing BrainEx90 or choosing specific types of goals influenced performance and satisfaction ratings of these goals. 217 individuals (44.4 ± 13.5 years old) with persisting symptoms following an mTBI completed BrainEx90, a 16-session interdisciplinary group outpatient rehabilitation intervention at Parkwood Institute between November 2013 and September 2019. Performance and satisfaction ratings of self-identified goals before and after BrainEx90 were assessed using the Canadian Occupational Performance Measure, and changes in ratings were analyzed using a linear mixed effects model. 1008 goals were identified and categorized as: productivity (45%); leisure (37%); and self-care (18%). Satisfaction ratings were significantly higher for all goal types following BrainEx90. Satisfaction with self-care goals improved significantly more than leisure [t(151) = 3.24, p <.01] and productivity [t(144) = 2.97, p <.01] goals. Performance ratings were also significantly greater following BrainEx90 [2.4, 95% CI [2.27, 2.53], p <.01)]. Performance and satisfaction of self-identified rehabilitation goals significantly improved following BrainEx90. Satisfaction with self-care goals demonstrated the greatest improvements, yet the most identified goal type was productivity. [ABSTRACT FROM AUTHOR]