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skills/treatment-plans/references/goal_setting_frameworks.md

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+# Goal Setting Frameworks for Treatment Plans
+
+## Overview
+
+Effective treatment goals are the cornerstone of successful patient care. This reference provides comprehensive guidance on creating SMART goals, patient-centered outcome selection, and shared decision-making processes for treatment planning across all medical specialties.
+
+## SMART Goals Framework
+
+### Definition
+
+**SMART** is a mnemonic for goal criteria that ensure objectives are well-defined and achievable:
+- **S**pecific
+- **M**easurable
+- **A**chievable
+- **R**elevant
+- **T**ime-bound
+
+### 1. Specific
+
+Goals must be clear, well-defined, and unambiguous.
+
+**Components of Specificity**:
+- **What**: Exactly what will be accomplished
+- **Who**: Who is responsible (patient, provider, both)
+- **Where**: Context or setting if relevant
+- **Which**: Specific aspect of health/function addressed
+
+**Examples**:
+
+| Poor (Vague) | Good (Specific) |
+|--------------|-----------------|
+| "Feel better" | "Reduce depressive symptoms as measured by PHQ-9 score" |
+| "Improve diabetes" | "Reduce HbA1c from current 8.5% to less than 7%" |
+| "Get stronger" | "Increase right quadriceps strength from 3/5 to 4/5 on manual muscle testing" |
+| "Lose weight" | "Reduce body weight by 10 pounds (from 210 to 200 lbs)" |
+| "Exercise more" | "Walk 30 minutes, 5 days per week" |
+
+### 2. Measurable
+
+Goals must include quantifiable metrics or observable criteria to track progress.
+
+**Types of Measurement**:
+- **Quantitative**: Numbers, percentages, scores, scales
+  - Lab values: HbA1c, LDL cholesterol, eGFR
+  - Vital signs: BP, heart rate, weight
+  - Scales: Pain (0-10 NRS), PHQ-9, GAD-7, FIM
+  - Functional: Distance walked, ROM degrees, strength grades
+  
+- **Qualitative Observable**: Behaviors that can be observed and verified
+  - "Patient demonstrates proper insulin injection technique"
+  - "Patient ambulates 150 feet with walker independently"
+  - "Patient follows 2-step commands"
+
+**Examples**:
+
+| Not Measurable | Measurable |
+|----------------|------------|
+| "Better blood pressure" | "Systolic BP <130 mmHg and diastolic BP <80 mmHg" |
+| "Less pain" | "Pain intensity reduced from 7/10 to ≤4/10 on numeric rating scale" |
+| "Improved mobility" | "Ambulate 300 feet with front-wheeled walker, supervision level" |
+| "Take medications regularly" | "Medication adherence >90% as measured by refill rates" |
+| "Sleep better" | "Sleep 7-8 hours nightly with <2 awakenings per night" |
+
+### 3. Achievable
+
+Goals must be realistic given patient's capabilities, resources, and circumstances.
+
+**Factors to Consider**:
+- **Patient capabilities**: Physical, cognitive, psychological capacity
+- **Severity of condition**: Advanced disease may have limited improvement potential
+- **Treatment efficacy**: What can realistically be achieved with available treatments
+- **Resources**: Access to care, medications, equipment, support
+- **Time available**: Adequate time to achieve the goal
+- **Motivation**: Patient's readiness to change and engagement
+
+**Setting Achievable Goals**:
+- Start with baseline assessment
+- Know expected treatment effects (e.g., metformin reduces HbA1c by 1-1.5%)
+- Set incremental goals for large changes (lose 5 lbs, then 10 lbs, rather than jump to 50 lbs)
+- Challenge but don't overwhelm patient
+- Adjust goals based on progress
+
+**Examples**:
+
+| Not Achievable | Achievable |
+|----------------|------------|
+| "Marathon ready in 1 month" (sedentary 70-year-old post-MI) | "Walk 1 mile continuously in 3 months" |
+| "HbA1c from 12% to <6% in 6 weeks" | "HbA1c from 12% to <9% in 3 months, <7% in 6 months" |
+| "Full knee ROM 0-140° by POD 3" (post-TKA) | "Knee ROM 0-90° by week 2, 0-110° by week 6" |
+| "Cure chronic pain" | "Reduce pain from 7/10 to 4/10 and improve function by 30%" |
+
+### 4. Relevant
+
+Goals must align with patient values, priorities, and overall treatment objectives.
+
+**Relevance Criteria**:
+- **Patient-centered**: Matters to the patient, reflects their priorities
+- **Clinically meaningful**: Achieving goal improves health or quality of life
+- **Aligned with diagnosis**: Goal addresses the condition being treated
+- **Appropriate timing**: Right goal for current phase of treatment
+- **Integrated**: Fits with other treatment goals
+
+**Assessing Relevance**:
+- Ask patient: "What's most important to you?" "What do you want to be able to do?"
+- Ensure goals address functional limitations that matter to patient
+- Connect clinical metrics to patient-meaningful outcomes (e.g., "HbA1c <7% reduces risk of vision loss")
+- Avoid provider-driven goals that don't resonate with patient
+
+**Examples**:
+
+| Less Relevant | More Relevant |
+|---------------|---------------|
+| "Reduce medication count" (when medications controlling symptoms well) | "Simplify regimen to improve adherence" (if missing doses due to complexity) |
+| "Perfect blood sugars" (patient's priority is energy) | "Improve energy levels through better glucose control" |
+| "Walk 5 miles" (patient just wants to shop independently) | "Walk through grocery store without assistance" |
+
+### 5. Time-Bound
+
+Goals must have specific deadlines or timeframes for achievement.
+
+**Timeframe Considerations**:
+- **Short-term goals**: Days to 3 months
+- **Intermediate goals**: 3-6 months
+- **Long-term goals**: 6-12 months or longer for chronic conditions
+- **Reassessment intervals**: Check progress at defined intervals
+
+**Time Elements to Include**:
+- Target date or timeframe
+- Checkpoint dates for progress review
+- Frequency of actions (e.g., "exercise 30 min, 5x/week")
+
+**Examples**:
+
+| Not Time-Bound | Time-Bound |
+|----------------|------------|
+| "Eventually lose weight" | "Lose 15 pounds within 6 months (approximately 1-2 lbs/week)" |
+| "Attend physical therapy" | "Complete 12 physical therapy sessions over 8 weeks, 1-2x weekly" |
+| "When ready, return to work" | "Return to modified duty work within 12 weeks post-surgery" |
+| "Improve depression symptoms" | "Reduce PHQ-9 score from 18 to <10 within 8 weeks of starting SSRI and CBT" |
+
+## Creating SMART Goals: Step-by-Step Process
+
+### Step 1: Assess Baseline
+- Identify current status: symptoms, lab values, functional level
+- Use standardized assessments when available
+- Document quantitative baseline
+
+### Step 2: Identify Desired Outcome
+- What needs to improve?
+- Engage patient: "What would you like to be different?"
+- Consider clinical needs and patient priorities
+
+### Step 3: Make It Specific
+- Define exact outcome
+- Eliminate vague language
+- Include all relevant details
+
+### Step 4: Add Measurement
+- How will progress be tracked?
+- What metric or observable behavior?
+- Baseline → Target value
+
+### Step 5: Reality Check (Achievable?)
+- Is this possible given patient's condition, resources, treatment effects?
+- May need to adjust expectations
+- Set incremental goals if needed
+
+### Step 6: Ensure Relevance
+- Does patient care about this goal?
+- Is it clinically meaningful?
+- Does it align with overall treatment plan?
+
+### Step 7: Set Timeline
+- When will goal be achieved?
+- When will progress be reviewed?
+- Break into short-term and long-term if needed
+
+### Step 8: Document and Communicate
+- Write goal in clear SMART format
+- Share with patient and care team
+- Ensure patient understanding
+
+## Goal Hierarchies and Levels
+
+### ICF Framework (International Classification of Functioning, Disability and Health)
+
+Useful for rehabilitation and functional goals:
+
+1. **Impairment-Level Goals**: Body structure/function
+   - Example: "Increase shoulder flexion ROM from 90° to 140°"
+   
+2. **Activity-Level Goals**: Task performance
+   - Example: "Dress upper body independently"
+   
+3. **Participation-Level Goals**: Life role engagement
+   - Example: "Return to work as teacher"
+
+### Medical Outcome Levels
+
+1. **Biological/Clinical Goals**: Lab values, vital signs, disease markers
+   - Example: "HbA1c <7%, BP <130/80, LDL <70 mg/dL"
+   
+2. **Symptom Goals**: Patient-reported symptoms
+   - Example: "Pain ≤4/10, no dyspnea with ADLs"
+   
+3. **Functional Goals**: What patient can do
+   - Example: "Walk 1 mile, climb 2 flights of stairs"
+   
+4. **Quality of Life Goals**: Overall well-being
+   - Example: "Return to hobbies, improve sleep quality"
+
+## Patient-Centered Outcome Measures (PCOMs)
+
+### Definition
+Outcomes that matter most to patients, beyond traditional clinical metrics.
+
+### Common PCOMs
+
+**Patient-Reported Outcome Measures (PROMs)**:
+- SF-36 or SF-12 (general health-related quality of life)
+- PROMIS (Patient-Reported Outcomes Measurement Information System)
+- Disease-specific QoL scales (e.g., Kansas City Cardiomyopathy Questionnaire for HF)
+
+**Functional Outcomes**:
+- Activities of Daily Living (ADLs): Bathing, dressing, toileting, transferring, feeding, continence
+- Instrumental ADLs (IADLs): Shopping, cooking, housekeeping, managing finances, transportation
+- Occupational/educational functioning
+- Social functioning and relationships
+- Recreation and leisure participation
+
+**Patient Priorities**:
+- What matters most to individual patient
+- May differ from clinician priorities
+- Examples: "Play with grandchildren," "Travel to daughter's wedding," "Avoid nursing home"
+
+### Integrating PCOMs into Goals
+
+**Approach**:
+1. Ask patient about priorities early in assessment
+2. Link clinical goals to patient-meaningful outcomes
+3. Include at least some goals directly addressing patient priorities
+4. Use patient's language in documenting goals when possible
+
+**Example Integration**:
+- **Clinical goal**: "Reduce HbA1c from 8.5% to <7% in 3 months"
+- **Linked patient-centered goal**: "Improve energy levels to play with grandchildren without fatigue"
+- Both goals documented, progress on both tracked
+
+## Shared Decision-Making in Goal Setting
+
+### What is Shared Decision-Making (SDM)?
+
+Collaborative process where clinicians and patients jointly:
+- Discuss treatment options
+- Weigh risks and benefits
+- Consider patient values and preferences
+- Make decisions together
+
+### SDM in Treatment Goal Setting
+
+**Steps**:
+
+1. **Choice Awareness**: Acknowledge multiple possible goals/approaches
+   - "We could focus on aggressive HbA1c lowering vs. minimizing hypoglycemia risk. What's more important to you?"
+
+2. **Option Presentation**: Present goal options with pros/cons
+   - "Option A: Intensive BP control (<120/80) reduces stroke risk but requires more medications. Option B: Standard control (<140/90) is easier but slightly higher stroke risk."
+
+3. **Values Clarification**: Understand patient priorities
+   - "How do you feel about taking multiple medications?" "How much does avoiding injections matter to you?"
+
+4. **Preference Integration**: Incorporate preferences into goals
+   - If patient prioritizes avoiding medications → "Control BP with lifestyle changes and one medication if possible"
+
+5. **Decision**: Agree on goals together
+   - "It sounds like you'd like to try intensive lifestyle changes for 3 months before adding another medication. Let's plan for that."
+
+6. **Document**: Record shared decision-making process
+   - "Goals established through shared decision-making. Patient expressed preference for..."
+
+### Decision Aids
+
+Tools to facilitate SDM:
+- Option grids comparing approaches
+- Numerical risk/benefit data
+- Patient stories/testimonials
+- Visual aids (pictures, diagrams)
+- "What matters to you" worksheets
+
+## Special Considerations for Different Populations
+
+### Older Adults
+- Functional independence often priority over disease-specific metrics
+- Balance aggressive treatment vs. treatment burden
+- Consider life expectancy and time to benefit
+- Fall prevention, polypharmacy reduction may be key goals
+- Quality over quantity of life
+
+### Pediatric
+- Developmental stage-appropriate goals
+- Family-centered (involve parents/caregivers)
+- Growth and development milestones
+- School/social functioning
+- Transition planning (pediatric to adult care)
+
+### Chronic Disease
+- Long-term sustainable goals
+- Balance ambition with realistic expectations
+- Complication prevention
+- Quality of life maintenance
+- Adaptation and acceptance alongside improvement
+
+### Palliative/End-of-Life
+- Comfort and symptom management primary
+- Functional goals focused on valued activities
+- Psychosocial and spiritual needs
+- Caregiver support
+- Dignity and autonomy
+
+### Complex Multi-Morbidity
+- Prioritize most impactful goals
+- Coordinate goals across conditions (when treatments overlap, even better)
+- Avoid conflicting treatments
+- Minimize treatment burden
+- Realistic expectations with multiple conditions
+
+## Common Goal-Setting Pitfalls
+
+### Pitfall 1: Provider-Centric Goals
+**Problem**: Goals reflect what provider thinks is important, not patient priorities  
+**Solution**: Ask patient early in visit what they hope to achieve, incorporate their language
+
+### Pitfall 2: Too Many Goals
+**Problem**: Overwhelming patient with 10+ goals  
+**Solution**: Prioritize 3-5 key goals, build on success
+
+### Pitfall 3: All-or-Nothing Thinking
+**Problem**: Goal is "cure" or "perfection"  
+**Solution**: Incremental goals, meaningful improvement valued
+
+### Pitfall 4: Ignoring Barriers
+**Problem**: Goals set without assessing feasibility (resources, support, access)  
+**Solution**: Identify barriers during assessment, problem-solve or adjust goals
+
+### Pitfall 5: Static Goals
+**Problem**: Set goals and never revisit  
+**Solution**: Regular reassessment, modify as patient progresses or circumstances change
+
+### Pitfall 6: Purely Clinical Metrics
+**Problem**: All goals are lab values, no functional or QoL goals  
+**Solution**: Balance clinical markers with functional, symptom, and QoL outcomes
+
+### Pitfall 7: No Patient Buy-In
+**Problem**: Patient doesn't believe goal is achievable or important  
+**Solution**: Shared decision-making, motivational interviewing to explore ambivalence
+
+## Examples of SMART Goals by Condition
+
+### Diabetes
+**Short-term**: "Reduce HbA1c from 8.5% to <7.5% within 3 months by initiating metformin 1000mg BID and reducing carbohydrate intake to 45-60g per meal."
+
+**Long-term**: "Maintain HbA1c <7% for 6+ months, prevent microvascular complications, and improve energy levels to engage in daily walking for 30 minutes."
+
+### Heart Failure
+**Short-term**: "Achieve euvolemia (no edema, stable weight within 2 lbs) within 2 weeks through furosemide dose optimization and sodium restriction <2000mg/day."
+
+**Long-term**: "Maintain NYHA Class II functional status, prevent HF hospitalizations, and walk 1/4 mile without dyspnea within 3 months."
+
+### Depression
+**Short-term**: "Reduce PHQ-9 score from 18 to <10 within 8 weeks by starting escitalopram 10mg daily and attending weekly CBT sessions."
+
+**Long-term**: "Achieve depression remission (PHQ-9 <5), return to work full-time, and re-engage in social activities with friends 2-3x/week within 4 months."
+
+### Post-Stroke Rehabilitation
+**Short-term**: "Increase right arm strength from 2/5 to 3+/5 and improve Functional Independence Measure (FIM) score from 85 to 100 within 4 weeks through PT/OT 5x/week."
+
+**Long-term**: "Achieve independence in all ADLs, ambulate 500 feet with cane on level surfaces, and return home (not nursing facility) within 3 months."
+
+### Chronic Low Back Pain
+**Short-term**: "Reduce pain intensity from 7/10 to 4/10 and increase walking tolerance from 10 minutes to 30 minutes within 6 weeks using multimodal analgesia (SNRI, NSAID, PT)."
+
+**Long-term**: "Return to modified duty work within 3 months, engage in hobbies (fishing, gardening with adaptations), and reduce pain interference on daily life by 50% (Brief Pain Inventory)."
+
+### Hypertension
+**Short-term**: "Reduce blood pressure from 152/94 to <140/90 mmHg within 4 weeks by initiating lisinopril 10mg daily and reducing sodium intake to <2300mg/day."
+
+**Long-term**: "Achieve and maintain BP <130/80 mmHg, reduce ASCVD 10-year risk from 15% to <10%, and prevent cardiovascular events."
+
+## Tools and Resources
+
+### Goal-Setting Templates
+- SMART goal worksheet (fill-in-the-blank format)
+- Goal-tracking sheets for patients
+- Motivational interviewing "change talk" to elicit goals
+
+### Assessment Tools
+- Goal Attainment Scaling (GAS): Personalized outcome measure
+- Canadian Occupational Performance Measure (COPM): Patient-identified functional goals
+- Patient-Reported Outcomes Measurement Information System (PROMIS)
+
+### Patient Education
+- "Setting Health Goals" handouts
+- Goal visualization exercises
+- Tracking apps and logs
+
+---
+
+**Document Version**: 1.0  
+**Last Updated**: January 2025  
+**Next Review**: January 2026
+