13.A3 Goal setting in person centred care

Person centred

In person centred care the client is an equal partner in planning, developing and accessing services to appropriately  meet  their needs.

A person centred approach puts the client and their family at the heart of all decisions.

It aims to:

  • Be client focused,
  • Promote independence and autonomy,
  • Provide choice and control and
  • Be based on a philosophy of collaboration and teamwork.
  • It takes into account the client's needs and views and builds relationships with the client's family members.
Which of the following goals are likely to be client generated goals?
Question and answers here

Which of the following are likely to be client generated goals?

Kate will contribute to her son’s school fete by supplying 4 cakes
Joanne’s anxiety will decrease by 3 points on the DASS
Joanne will attend her daughter’s ballet recital
Steven will be able to join his mates at their weekly outing to the pub
David’s deep neck flexor strength will improve from grade 2 to grade 4
David will return to work 4 hours/day, 3 days/week
Kate will be able to comprehend a 5-step written instruction
NOTE For those going on to Part B in Clinical Settings: In Part A a person centred approach always implies client generated goals(not just client focussed goals or clinician goals).

A person centred approach gives people:

  • valued roles
  • participation and belonging in the community
  • freely given relationships
  • greater authority over decisions about the way they live
  • genuine partnership between the service, themselves and/or their family and allies
  • individualised and personalised support arrangements.

Person-centred approaches require that organisations:

  • have a committed leadership that actively instills the vision of a person-centred approach at all levels
  • have a culture that is open to continual learning about how to implement a person-centred  approach
  • consciously hold positive beliefs about people with a disability and their potential
  • develop equal and ethical partnerships with people with a disability and their families
  • work with people to individually meet each person’s needs so that they can be in valued roles in valued settings
  • develop appropriate organisational structures and processes


Signs of a person centred approach

There are many signs of person centred approaches; and signs of approaches that are not person centred.  Some examples are:

Signs of a person centred approach 

  1. Making sure the person and their friends and family are central to identifying needs.
  2. Focussing on the future e.g. identifying that a person will need to cook in their own home.
  3. Asking the person what they should most like.
  4. Enabling people to have lots of experiences so they can make informed choices
  5. Thinking not only about choice, but also about how people can have more control over their own lives.
  6. Expecting that everyone is born into a common humanity and deserves a ‘good’ life
  7. Service providers recognise that the person/family has important knowledge about their own needs and about how these are best met.
  8. Supporting the person to have valued roles in the community

Signs of NOT being person centred

  1. Thinking about the person mainly in terms of what they cannot do.
  2. Focussing only on the present, e.g. identifying that a person must learn to cook.
  3. Telling a person what the decision is after it has been made.
  4. Expecting that people will immediately be able to make good decisions without support.
  5. Expecting that people with a disability cannot have lives like other people.
  6. Expecting that having a disability means having more in common with each other than with other citizens.
  7. Service providers holding all the power and controlling what happens to the person.
  8. Supporting the person only in the role of service client or other non-valued roles, fitting the person into activities and programs.

Goal directed


In person centred care:

  1. Goals are what the client wants to achieve.
  2. Goals belong to the client, not to workers, clinicians or service providers. 
  3. Rehabilitation programs exist so that clients can achieve their goals. 
  4. Rehabilitation goals typically focus on improvement.
  5. Clients have life goals after rehabilitation – including maintain goals and prevent deterioration.

Benefits of setting goals

Setting client goals:

  1. Helps clients motivate themselves – i.e. it is easier to work towards achieving your goals when those goals are explicit and you are clear about what you are wanting to achieve.
  2. Makes it clear to everyone what the the client is wanting to achieve.
  3. Makes it easier for everyone working with the client to work together as a team and coordinate their efforts to achieving the goals.
  4. Makes it easier for everyone to see how well things are working: Are the goals being achieved?

Individual service plans

Individual service plans are needed so that the steps needed to achieve the goals are documented and everyone involved is working together.

Individual service plans:

  • Start with the client's goals
  • Establish the steps needed to achieve the client's goals
  • And then design the actions and services needed to achieve the steps.




What's to be achieved

Useful goals describe what the client wants to achieve, not what the client or service provider is supposed to do.  The program describes what is to be done.

Jill’s goal: To be able to care for her child independently.
Jill’s program: Jill does her home exercise  program and attends occupational therapy sessions. 
She does this because she wants to be able to care for her child independently.

Sometimes goals do not reflect what the client wants to achieve in their life. For example if Jill’s goal were written as: To do the home exercise  program each day and attends occupational therapy each week this would not be an appropriate goal, as it is focussing on what Jill has to do, not what she wants to achieve.

It is useful to start with person centred goals.

Clinicians may need to establish clinical goals to address impairments, but these need to be seen as a means to an end.


Person centred participation goal

Person centred activity goal

Clinician's goal to address impairment


Kate will contribute to her son’s school fete by supplying 4 cakes


Kate will be able to follow a recipe to make a cake


Kate will be able to comprehend a 5-step written instruction


Steven will be able to join his mates at their weekly outing to the pub


Steven will be able to independently transfer from wheelchair to car


Steven’s hip extensor strength will increase from 3/5 - 4/5


Joanne will attend her daughter’s ballet recital


Joanne will be able to be in the company of unfamiliar people for >45 minutes without experiencing an anxiety attack


Joanne’s anxiety will decrease by 3 points on the DASS


David will return to work 4 hours/day, 3 days/week


David will be able to work at a computer for 4 hours without experiencing pain greater than 3/10


David’s deep neck flexor strength will improve from grade 2 to grade 4



Engaging clients

Pre-existing and injury related factors can effect the extent to which the client can engage in the goal setting process

Injury related
  • personality type
  • lifestyle
  • health conditions e.g. mental health, level of functioning
  • attitude to goal setting and life planning
  • cognitive impairment
  • insight into nature of disabilities and
  • current level of function
  • knowledge about anticipated recovery
  • adjustment to disability after injury
  • mood / mental health issues


Goal setting is a complex process and it is unrealistic to expect that all clients will be able to formulate goals without assistance, as not everyone consciously uses a goal framework to manage their daily lives.

Clients may need to receive training in goal setting and the rehabilitation process so they better understand what is required and how the goals will be used in their rehabilitation. Even cognitively intact clients with great self-awareness may require advice from service providers or health professionals regarding what is realistic within certain time frames.

It is not realistic to expect clients to express goals with all the elements of a SMART goal (see following section). The impact of injury and any pre-existing conditions can impair people’s ability to understand and engage in a goal setting process.

Tools for Engaging Clients in Goal Setting


Informal strategies can be a useful starting point, especially with those clients with less complex and recoverable injuries.

Engaging the client to identify their rehabilitation goals may be as simple as using the following prompts:

  • ‘What can’t you do since your injury that you’re keen to get back to?’
  • ‘What are you finding more difficult since your injury that you’d like to be easier?’
  • ‘How will you know when you’re ready to stop coming to see me?’

More formal strategies for interviewing the client and objective goal tools are also

In essence, these tools are all based around identifying a client’s values, and what activities they would like to be able to do. They can be useful for those who do not feel confident to engage clients in conversations to identify their rehabilitation goals and for clients who are difficult to engage. Not all tools will be useful for all clients or services. Examples include:

  • Canadian Occupational Performance Measure (COPM)
  • Goal Attainment Scaling (GAS)





Clients with limited insight

Cognitive impairment, lack of insight into the impact of their injuries and low or impaired mood can all reduce the client’s ability to judge their current status and what goals are reasonable and realistic.

Clients may need help in understanding that in order to achieve their long-term goals, other things will need to be achieved first, e.g. to achieve their goal of getting back to work, they first need to be able to walk without assistance, be able to sit without pain, and be able to get up and catch bus to their workplace and arrive on time.

Collaboration between the client and service providers and/or clinicians is needed to identify what is and is not achievable and to resolve discrepancies where possible.

When clients are unrealistic they can identify goals that are unlikely to be achievable in the foreseeable future - balance is needed between the goals identified by the client and the timeframes for service delivery and funding.

Bigger and longer term goals may need to be broken down into several goals and many steps.

Service providers and/or clinicians need to ensure that the client gains an understanding of the link between current steps and actions and their longer term goals.

When substantial amounts of services are required (i.e. high cost), the client’s ultimate goal may need to be broken down into several client focused goals so the link between the action plan and anticipated change in the client is clear.

This is acceptable as both goals and steps describe how the client will benefit from the recommended action plan.