Creating the Care Plan using S.M.A.R.T. Goals

Transcription

1 TOPIC The purpose of this guide is to help the Case Manager develop SMART Goals and individualize the plan of care for their members. References Outpatient Case Manager Role in under Medical Management Portal has several modules to support Special Needs Plan training and Individualized Care Plan overview. ADAM-can use to help guide the case manager in narrowing down what problems and interventions to discuss for a certain condition. Contents Contents SMART Goals... 2 Developing a SMART Goal... 2 Tips for creating SMART Goals... 3 Things to Avoid... 4 Manually Entering a SMART Goal in TRUCARE... 4 Correcting a Goal... 6 EXAMPLE of using SMART... 7 CESD/ WellMed Medical Management Page 1 of 8

2 SMART Goals A learning goal describes what the member wants/needs to learn or achieve. A S.M.A.R.T. Goal stand for the following: S- Specific, significant, stretching M- Measurable, meaningful, motivational A-Agreed upon, attainable, achievable, acceptable, action oriented R- Realistic, relevant, reasonable, rewarding, results-oriented T-Time-based, timely, tangible, tractable Developing a SMART Goal 1. The case manager will need to start by reviewing all available information related to the problem/problems that would be appropriate for the member. This might include things such as the United IVR HRA or CM/DM General Adult Assessment, Disease-Specific Assessments, claims, authorizations, medications, etc. 2. Be specific and write it down in one sentence. 3. Do not use vague phrases such as Member will understand. Use an action verb to describe what is to be achieved. Using an action verb makes sure the goal is measurable. Examples of action verbs are: Identify State Develop Plan Design Compare Describe Evaluate Explain Demonstrate Create 4. The goal needs to be realistic for the member and one that the case manager has identified as appropriate at this time. 5. The timeframe for the goal focuses on when the goal should be reached. (Can be documented in the TruCare in the Target date section of the care plan) CESD/ WellMed Medical Management Page 2 of 8

3 Tips for creating SMART Goals S-Specific: Creating the Care Plan using S.M.A.R.T. Goals 1. A specific goal has a much greater chance of being accomplished than a general goal. 2. To set a specific goal the 5 W s will help the case manager achieve greater specificity: Who: identify person to implement What: Reduce A1C Where: At home When: Today or 3 months from now, can put a specific date for this Why: To improve diabetic condition 3. The clearer the case manager is in this goal setting phase, the easier it will be to devise a plan and for the member to actually accomplish their goal. M-Measurable 1. Member goals should be measurable in time specific intervals 2. The member needs to feel and see the accomplishment sooner rather than later 3. The case manager needs to ask themselves these 3 important questions: Can this goal be measured? How will the member know when they have achieved their goals? Where does the member want their goals to take them? A-Attainable 1. Are the member s goals Attainable? In other words, do not make goals that are not realistic to achieve, since this defeats the whole purpose of setting them. 2. If the member sets unattainable goals for themselves, they will be disheartened and eventually lose motivation to continue. 3. So keep in mind exactly why the goals the member sets are important. Remember why these goals are being set. R- Relevant 1. This relevance of a goal is an important factor. Relevance means that it has the potential of influencing the member s objectives, vision and/or values. 2. Will this goal improve the condition of the member? What is the value of the goal that is being set? 3. Plan according to the relevance of the goals so the effort and resources being used by the member and the case manager are not wasted on tasks that do not deliver. 4. Make the goals relevant to what the member wants so they will be motivated to accomplish them. CESD/ WellMed Medical Management Page 3 of 8

4 T- Time Creating the Care Plan using S.M.A.R.T. Goals 1. Goals need to have a deadline in order to direct the work being done. 2. The deadline is not to stress the member or the case manager working with the member but to motive both to accomplish what can be done and to help the member move forward in terms of their health. Do not hesitate to set timeframes with the members 3. This timeframe should not be general like a year from now, make it an incremental goal time frame, ie. 3 months from now, on 3/31/ Multiple timeframes can be used for the same goal to show progress, create motivation and organization for the member. This will give them a sense of accomplishment. Set it for a week, month and even 3 months from now. Doing this gives deadlines meaning, purpose and holds everyone accountable with clarity of what is expected and when Things to Avoid Avoid using terms that don t allow a margin for error such as always, every, each, all and never. Avoid describing negative goals as things member should not do, focus on what they should do instead. Manually Entering a SMART Goal in TRUCARE NOTE: TRUCARE does not always have pre-formatted SMART goals that meet CMS requirements. The Case Manager will need to enter a SMART Goal manually and add it to the Care Plan. To Create a goal in TRUCARE follow the steps below: 1. Select the problem that will be addressed and expand problem section 2. Move down to the Goal Section: Click on the dropdown and select Other CESD/ WellMed Medical Management Page 4 of 8

5 3. Enter SMART Goal into the blank text box. Choose appropriate Readiness to Change state. Select Create. This will move the goal to the bottom of the goal list. 4. The case manager can still delete the goal at this point by clicking on the white X inside the red circle. 5. Expand the goal the case manager is working: a. Enter a Target Date to ensure goal is time based ( the case manager may also include this in the problem) b. Identify if Short term or Long term goal and if this is a member set goal i. Typically short term goals are those for less than 3 months. However, this can different due to member s health history. ii. To identify a member set goal, click the member set goal box c. Designate a goal Priority as compared to other goals d. Select a Barrier or select Other and type in the text box: no barrier identified e. Move down to the intervention section CESD/ WellMed Medical Management Page 5 of 8

6 Enter individualized interventions for the member. Ensure they tie back to the problem and goal. Be specific, and follow the same process for manually entering goals Correcting a Goal In the event that the case manager identifies a goal has been created that is not considered a SMART goal, the case manager will need to update the care plan to ensure it reflects a measurable goal or will lose points in an audit for not being SMART. Tips: It is best to create the updated goal first to allow the case manager to refer back to the original if needed 1. Open the problem that the goal is under 2. Scroll down to the goal sections within the problem and create a new goal using STEPS 1-3 above. Use same dates as original goal or change if necessary 3. Once the case manager has completed the updated goal, return to the non-smart goal 4. Open the interventions section and close out the task a. Select Changed as the Closed Reason b. Select Effectiveness as appropriate c. Click Submit. This will take the case manager back to the goal section 5. Close the non-smart Goal a. Enter today s date as the closed date b. Select Changed as the Reason c. Select Outcome Type as appropriate CESD/ WellMed Medical Management Page 6 of 8

7 EXAMPLE of using SMART To write a goal, use this sentence to get you started: Member will action verb (what the member has agreed to do) by timeframe. Here are some examples: 1. Member is complaining for increasing pain in her back, is affecting her mobility. Problem: Acute pain SMART goal: Member will make (an appointment with a pain specialist to evaluate her back pain) by 4/15/16. Intervention: Case manager will provide 3 pain specialists contact information to the member so member can call for an appointment. 2. Member has heart failure, has a tendency to have weight gains due to not following the low salt diet. Problem: Risk for excess fluid volume SMART goal: Member will describe (the guidelines for a low salt diet) by 4/15/16. Intervention: Case manager will provide education on the low salt diet, will provide resources on cooking with replacement spices from ADAM. 3. Member has COPD that has gotten progressively worse over the past year. He is having more trouble getting around due to SOB. Problem: Activity Intolerance SMART goal: Member will walk (20 feet 3 times a day) by 5/15/16. Intervention: Member will start walking 10 feet once a day until he can do this without SOB, will gradually increase the distance and frequency until he is able to walk the distance discussed. CESD/ WellMed Medical Management Page 7 of 8

8 SMART Example ( Diabetic ) Specific Specific and significant Well Defined Clear to anyone that has a basic knowledge of the patient condition Don t use words like understand, comprehend, know, grasp, etc. Measurable - Objective and/or subjective data to measure if the goal was completed. Action oriented, reduce, take, verbalize, etc. Agreed Upon/ Attainable - Attainable, achievable, acceptable and action-oriented Agreement between the case manager and the member of what the goals should be when possible Realistic - Relevant, reasonable, rewarding and results-oriented, goal must represent something a member is willing to be able to work toward. Timely - Timely, tangible and trackable Enough time to achieve the goal Goal should be grounded within a time frame A general goal would be Member will verbalize understanding of Diabetes and complications of the disease process but a specific goal would s Patient will correctly verbalize 2 co-morbidities associated with uncontrolled diabetes In the next 3 months. Member will reduce his A1C by two points in 3 months Member will verbalize 2 fall risks in the home and correct these hazards by end of the month. Click on member set goal box in TruCare Five days each week member will take a 30 minute walk during the lunch hour, will be started by 4/30/16 (realistic and specific) Member will reduce his A1C by two points in 3 months TruCare has Target Date to enter To ensure goal is time based. CESD/ WellMed Medical Management Page 8 of 8