GOAL SETTING

EKOS - a SMART solution

Community Stroke Teams in Nottingham have been using the East Kent Outcome System for 7 years as an integral part of case management. Frustrated by the lack of peer reviewed published articles on EKOS, Margaret Metcalfe argues that its special features make it an invaluable tool for clients, therapists, teams, managers and commissioners.
READ THIS IF YOU HAVE CLIENTS WITH COMPLEX AND CHANGING NEEDS AIM FOR AN INTERDISCIPLINARY APPROACH SEEK A SUSTAINABLE OUTCOMES SYSTEM

Our priorities were to create aims that would both demonstrate the range of our involvement with people and allow the client to set their goals and work towards them with any member of staff involved. We didnt want to create aims for each profession. Instead, we wanted aims that reflected the goals of our clients and enabled each member of staff to offer appropriate interventions for that identified goal. Such aims could include: To enable [the client] to participate in [their chosen leisure interest] To enable [the client] to engage in voluntary work / paid work / education To enable [the client] to improve their psychological wellbeing. Margaret Metcalfe (front left) with members of the County Community Stroke Team in Nottingham n Nottingham we have two Community Stroke Teams made up of occupational therapists, physiotherapists, specialist mental health nurses, speech and language therapists and rehabilitation support workers. We see people at home and in other community settings and seek to work together to offer coordinated care that is focused on what the client (and their significant others) want. In 2000 we were aware that our goal setting with clients was somewhat ad hoc. We did not review it systematically, and it didnt give us data that could be presented to managers about the outcomes we were achieving. I was asked to look for a system we could use - and that would give us some quantifiable information. Given the complex nature of our clients and the inter-disciplinary approach we use, we didnt feel that the Barthel Index (Mahoney & Barthel, 1965) would provide sufficiently sensitive information. In any case, it doesnt collect data on communication, swallowing or mental health needs. We also looked at Therapy Outcome Measures (Enderby & John, 1999). Again we felt these would not give information about the range and complexity of our work. We also wanted a system that would allow people to set their own goals. A team occupational therapist and I attended a day run by Maggie Johnson on the

East Kent Outcome System (EKOS) (Johnson, 1997; Johnson & Elias, 2002). Before the day had even concluded we both felt that this system would provide quantifiable data, and work in a person-focused way across a variety of timescales with whatever complexity of clinical need. We recognise that EKOS is not an outcome measure per se but a system that can demonstrate goal achievement using the goals of the client rather than the goals of the team. Specific uni-professional outcome measures can also be used within the system where appropriate.

this system would provide quantifiable data, and work in a person-focused way across a variety of timescales with whatever complexity of clinical need
Some aims are more likely to be unidisciplinary. For example, To enable [the client] to maintain muscle length and joint range of movement is most likely to involve the physiotherapist rather than other members of the team, but this is not the principle we wanted overall. The goal sheets (available at www.speechmag.com/Members/Extras) remained very similar to the sheets we were used to working with. There was a column for what was happening already and a column for the goal and whether or not it was achieved, with a review date identified, but we added the ingredients of EKOS to enable quantifiable information to be gathered: 1. a box for the Health Benefit. Based on World Health Organisation guidelines, these are Reassuring, Resolving, Restoring, Preserving, Modifying, Avoiding Harm, Supporting, Promotion and Informing.

Making it happen

When we offered EKOS as an option to the team they agreed to explore its use, and work began to develop the processes we needed to apply it in our setting. As a whole team (then 8 people of the disciplines mentioned), we met for two afternoons to: discuss the concepts of EKOS agree our team aims (EKOS has elements that are consistent across teams and elements that are developed by the team to demonstrate the particular work of that team) adapt our existing goal sheets to use the EKOS ingredients agree ways of making EKOS happen.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2010

GOAL SETTING
Assessment is the process by which we select the appropriate health benefit, not a benefit in itself. Our health benefit sheet, including coding, definition, examples and helpful hints is available at www. speechmag.com/Members/Extras. 2. a specified Aim on the sheet to ease administration. 3. a place for giving the Outcome and the Contributing Factor if appropriate. Contributing factors recognise that outcomes can be affected negatively by a variety of things. These may be within or outside of our control and can include things like the goal set was too ambitious, the client became ill, or the client did not engage in therapy. Other teams might also add a box for Client Group but we dont need this. For collecting information there are EKOS codes for health benefits and contributing factors, so we also created codes we could use for our aims (figure 1). We continue to use the goal sheets we created at the start and have added aims around pain and advising on selfmanagement, as we found our clients needs demanded this. When we have been able to use the system with joint goal setting and review, it has been very helpful, successful and motivating. While individual clinicians also continue to find EKOS useful when used in a unidisciplinary way, we have found - in common with every other goal setting system - that the usefulness of EKOS depends on the clinician using it. EKOS requires not only the ability to write SMART (Specific, Measurable, Achievable, Relevant / Realistic, Time-bound) targets, but agreement that focused goalsetting is useful, and the willingness to confer with colleagues when the benefits of intervention are perceived as hard to quantify. Since setting up the system there have been significant changes in staffing and team structures and it has been harder to maintain the original enthusiasm and rationale for adopting the system. We have built time in to our regular case discussion to look at and discuss goals especially when there are difficulties with setting SMART goals, as there inevitably are with some people with complex needs. We are also looking at initiatives such as clinical audit to recapture the clinical focus of our first meetings. We have been unable to secure funding or support to develop a database to gather and return the information we would like to be able to present. We have therefore set aside half a day a year to collate the numbers of good and poor outcomes overall, health benefit to outcome, aim to outcome and also the relevant contributing factors, and create a report.

Figure 1 Aims for the Community Stroke Team EKOS Plan To enable client to participate in their chosen leisure interest To enable client to reach their desired potential in - domestic activities of daily living - personal activities of daily living To enable client to engage in voluntary work or paid work or education To enable client to participate in satisfying conversations To enable client to receive the service they want/need To enable client to use appropriate transport To provide reassurance that no intervention is needed To maximise normal movement To enable client to move safely in their desired environment To enable client to improve their psychological well being To support and / or maintain and / or improve existing social circumstances To enable client to access and use written material to their potential To provide information / assessment / support to enable client to make choices around food / fluid intake methods that are safe and to potential To enable the client to set realistic objectives To enable client to maintain muscle length and joint range of movement To enable client to engage in interaction To support carers through their reaction to the current situation To facilitate pain management To provide advice, information and support to enable client to continue their future rehabilitation LEI ADL

WRK CON SER TRA REA MOV SAF PSY SOC WRI SWA OBJ MUS INT SUP PAI ADV

Scaling (initially developed in 1968 by Kiresuk & Sherman), there is very little about EKOS. The managers also report that commissioners want a sense of the impairment level at which people enter the service and the level they attain when they leave (such as given

we have found - in common with every other goal setting system - that the usefulness of EKOS depends on the clinician using it
by the Barthel Index) rather than data about good and poor outcomes linked to a range of health gains following intervention. However, a recent meeting with commissioners indicated significant interest in the reports generated by EKOS and this is being pursued. I understand that commissioners in other regions have also been impressed with EKOS, which is encouraging.

Significant interest

The lack of peer reviewed published articles about EKOS has led some managers in the teams to feel uneasy about using it. While there are multiple articles written about other outcome systems such as Goal Attainment

EKOS has brought many benefits to our team: 1. It has improved collaboration within the team by giving us a common vocabulary for discussing clients and looking at their progress and expectations. 2. It is a flexible system that allows for change in response to client needs and clinical initiatives. 3. It has focused our interventions because it provides for systematic reviews and therefore indicates to clinician and client when therapy can no longer be useful. 4. The focused interventions have also decreased contact time while goals are still usually being met. 5. It has enabled clients to recognise their achievements and progress and made it evident when the team has completed useful interventions on occasion people have said to us that, although they want to go on improving, they can see that they no longer need our intervention for that to happen. 6. Within the Community Stroke Teams we have peer supervision for clinical interventions and so the EKOS goals have helped to focus these discussions on improving planning, engaging clients and setting goals.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2010

GOAL SETTING
We have also found the idea of Contributing Factors useful. Paying attention to this has enabled us to look at what is within our control and reflect on aspects of our learning and practice, as well as demonstrating the times when the poor outcome was outside our control (see case example in figure 2). We have found our annual report useful for ongoing learning as a team, as it identifies where we can get better at writing SMART goals and how we can improve on how we demonstrate the range of our work. The report enables us to see the aims and health benefits that we recognise are relevant to our client group but which we have not used very often for example, last year we noticed our Health Promotion had not been consistently documented. It is also useful for highlighting the areas in which we and our clients do well along with areas that need attention. This helps us recognise where we need some clinical education and development or to work with other teams. For example we consistently achieve more than 80 per cent good outcomes in improving function in activities of daily living. However, for our work in maintaining function where there is a co-existing deteriorating neurological condition, we only achieve around 50 per cent good outcomes. After a successful trial period, EKOS has been a mandatory part of case management within our service for 7 years. As a team we continue to feel that EKOS adds sufficient benefit both to our clients and to us as staff to keep it as an expected aspect of management. Our managers are now asking us to collect Barthel Index scores and the Euroquol (Euroquol Group, 1990) pre- and post- our intervention to supplement the information on achievement of goals. We will continue to review the value of EKOS and its use within the team and to deal with the queries that arise, ensuring that it remains relevant to clients, their families, the team, management and government priorities. SLTP Margaret Metcalfe is principal speech and language therapist with Nottinghamshire Community Health, e-mail Margaret.Metcalfe@ nottscommunityhealth.nhs.uk.
References Enderby, P.M. & John, A. (1999) Therapy outcome measures in speech and language therapy: comparing performance between different providers, International Journal of Language and Communication Disorders 34(4), pp.417-429. Euroquol Group (1990) Euroquol - a new facility for the measurement of health-related quality of life, Health Policy 16, pp.199-208. Johnson, M. (1997) Outcome Measurement: towards an interdisciplinary approach, British Journal of Therapy and Rehabilitation 4(9), pp.472-477. Johnson, M. & Elias, A. (2002) East Kent Outcome System for speech and language therapy. Eastern & Coastal Kent Community Services. (E-mail Annie. Elias@eastcoastkent.nhs.uk) Mahoney, F.I. & Barthel, D. (1965) Functional evaluation: the Barthel Index, Maryland State Medical Journal 14, pp.56-61.

Figure 2 Case example Gavin

Gavin was referred to the Community Stroke Team needing intervention from occupational therapy, physiotherapy and speech and language therapy. His intervention lasted 14 months and we wrote 12 sets of goals with him during that time. Gavins goals were shared so that I was involved in encouraging him to make a hot drink. At the same time, the occupational therapist and physiotherapist knew the particular areas of difficulty in communication and so when to actively support conversation and when to give Gavin more time to work on his output. On the occasion that a reading goal was not achieved the Contributing Factor was Over Ambitious Goal. This led me to reflect on my expectations of work on reading and to adjust the timescales to appropriately reflect the complexity of what we were hoping to achieve. The goal sheets reflect the fact that the goal was re-set and achieved next time, showing that time was the relevant factor. Gavin said of the goal setting process, When I know I am good then it helps me. I asked him to clarify what he meant. He indicated in the conversation that it is hard to feel that he is making progress and so having evidence of his progress is encouraging and motivating.

Editors choice

So many Journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.

The exploratory study Examining the Communicative Function of Challenging Behaviour in Fragile X Syndromeuses parental report and contrived scenarios to investigate what reinforces aggressive, destructive and self-injurious behaviours. Langthorne & McGill suggest that, rather than using challenging behaviour for social attention, children with fragile X are more likely to be motivated by a wish to escape from unpleasant situations or to access preferred items or activities. While the authors highlight the studys flaws, the contrived situations approach has potential, as does the conclusion that, with this information, we can teach the child different ways of meeting these needs at an early age. The Fragile X Society Newsletter Research Supplement (2009) November, Issue 48 Sometimes research seems obvious but draws attention to and extends understanding of how to address difficult issues and develop services. In The Loneliness Experiences of Young Adults with Cerebral Palsy who use Alternative and Augmentative Communication, Cooper, Balandin & Trembath find that support networks, AAC systems and communication technologies mitigate experiences of loneliness. The reported exchange with Frank (p.158) shows the importance of giving clients the opportunity to discuss things rather than making assumptions. In this case his mother learnt he didnt like her speaking for him, so was able to change. Augmentative and Alternative Communication (2009) 25(3), pp.154-164. Ive always struggled with kids whose problems with speech appear to be associated with ear, nose and throat issues. Do you wait for surgery or begin therapy straight away? Lundberg, McAllister, Samuelsson, Ericsson & Hultcrantzs Phonological development in children with obstructive sleep-disordered breathing confirms that surgery helps other problems with which adeontonsillar hypertrophy is associated. However, it does not resolve phonology problems, perhaps because the learned pattern has been internalised. The authors say tonsillotomy may be a better surgical option than tonsillectomy, and that speech and language therapy needs to start as early as possible. Clinical Linguistics & Phonetics (2009), 23(10), pp.751-761.

Remember to check out the members area of www.speechmag.com for extras from this article!
REFLECTIONS DO I RECOGNISE THE IMPORTANCE OF CLINICAL LEADERSHIP TO A TEAMS ENTHUSIASM, ORGANISATION AND FOCUS? DO I FORM CLIENT-LED GOALS WHICH ARE SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT / REALISTIC AND TIME-BOUND? DO I APPRECIATE HOW WRITING UP AN APPROACH CONTRIBUTES TO ITS FUTURE CREDIBILITY?

In view of the lack of peer reviewed articles on EKOS, a Critical Friends appraisal of this article would be particularly welcome. See www. speeechmag.com/About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2010

Health Benefits
Code Health Benefit Definition Determining that a clinical intervention is not required and reassuring the client and family that no intervention is needed. Resolving a clinical condition at either a symptomatic or causative level or reducing the problem to an acceptable level for the client. Restoring function as fully as possible after loss skills. Course of progress may involve use of aids and adaptations to the environment. N.B. full recovery not possible. Arresting or slowing down loss of normal function where deterioration is inevitable. This may involve use of aids and adaptations to the environment. Making social and physical modifications to the clients environment when further improvement in functional ability is unlikely or very gradual over time. Reducing negative effects of disability and prompting inclusion and quality of live. Reducing the risk of harm to clients, or of clients causing harm to others. Supporting clients and their families through situations resulting in pain, fear, grief, confusion, anger or guilt so that they may retain dignity, purpose, choice and self worth within the constraints of their situation. Preventing future health problems by achieving and maintaining a satisfactory level of healthcare. Proving a specialist opinion or assessment, which will inform another professionals decisions about a client. (Responsibility for effecting change lies with receiving agency). Determining whether or not intervention is appropriate at the present time; establishing a diagnosis and forming an opinion as to nature of intervention and outcome. Examples If on assessment we see that no intervention is needed, this would be used. This is going to be rare since it assumes no or very mild residual effects from the stroke. Many of our clients fall into this category. Its about doing things again, with or without adaptations.

HINT !
Therapy not needed but client may not be ready to let go yet

RSR Reassuring

RSV Resolving

You hope to cure and discharge Achieving potential acquired conditions.

RST Restoring

PRE Preserving

If someone has a progressive Its going to get disease as well as a stroke some worse aspects of our work may be PRE. Client cant change anymore but we can change external factors

MOD Modifying

Not the equipment that enables greater function but changing the environment to take account of their abilities/difficulties.

AVH Avoiding Harm

SPP Supporting

Reducing a risk of falling, choking, contractures, any other secondary conditions Use this when this is the only focus of this specific intervention.

Accident prevention Its natural to feel like this. Targeting ability to cope on a day to day basis.

PRO Promotion

IFR

Informing

This would be general health advice for promoting good heath. But again this needs to be the focus. Wed rarely use this. Perhaps if a report is requested on someone weve known previously.

Avoiding gradual emergency of health problems.

Report only. Nofollow up unless update required

Assessment (process by which we select appropriate health benefit)

Not a heath benefit in its own right; but one-off assessments will frequently be linked to RSR or IFR. Ongoing assessment is often part of an intervention programme an can accompany any of the above benefits.

From Metcalfe, M. (2010) EKOS a SMART solution, Speech & Language Therapy in Practice Spring, pp.4-6.

Community Stroke Team Plan Name: .. D.O.B: Aim: Whats happening now (Baseline) What well do (Interventions) What I want to happen (Objective) /X What happened (Actual Outcome) Health Benefit:

This plan was agreed between ____________________________ and _______________________________ on ________________

From Metcalfe, M. (2010) EKOS a SMART solution, Speech & Language Therapy in Practice Spring, pp.4-6.

Review Date _______________________________ Overall Outcome _______________________ Contributing Factors ________

From Metcalfe, M. (2010) EKOS a SMART solution, Speech & Language Therapy in Practice Spring, pp.4-6.