Rehabilitation is a team activity, and meetings of all team members are essential for team members to share information, understand the situation, work out what is possible, choose the most appropriate options, and plan the collective and individual actions. A single meeting will likely cover many or all these functions. Still, it is worth considering formulation and planning separately because each needs to be understood fully and done well. I discussed the process required to agree on the formulation here. This page considers meetings convened to plan the patient’s rehabilitation: the long- and short-term goals, who is going to do what, when and with whom, when will the next team review occur, how are activities coordinated, etc. These are not trivial matters, and the effectiveness of the patient’s rehabilitation depends crucially on good planning.
Preamble and context
Not every patient needs a meeting with the rehabilitation team. Not all rehabilitation is complex, requiring the involvement of an entire team. In straightforward cases, it is reasonable for a single clinician to provide the rehabilitation with two conditions attached:
- the clinician involved is integrated within a multi-disciplinary team and has unfettered and, if necessary, rapid access to other team disciplines;
- the clinician involved has expertise in rehabilitation (see here) and their specific professional knowledge to recognise when other team members are needed.
Under these circumstances, which may account for most patients seen, no formal meeting is required. Additionally, a few patients who see only two or three team members, usually only on one occasion to check something or give essential advice, and who have only a short spell of rehabilitation may also not need a meeting.
However, many patients involved in rehabilitation will receive input from more than one or two professionals. Indeed, many patients will be in contact with more than one team or service. The more people involved with a patient, the greater the risk of wasting resources through duplication or poor coordination, missing problems or failing to treat them thinking someone else is. These failures may cause the patient harm.
Second, a meeting should happen for any patient seen over prolonged periods with many attendances because a single professional may not notice or be aware of a change or other problems. Prolonged attendance even with only one person involved suggests a more complex case, and a meeting with some other team members may reveal previously unnoticed issues.
The natural solution to the risk of waste and harm is for all those involved to meet, achieve a better understanding through the previously described formulation and execute a coherent and organised plan with coordination and sharing of activities. This page considers these meetings.
Name for the meeting.
These meetings go by many names. For example, the following terms would all fall within the meaning of a “rehabilitation planning meeting”: goal planning, goal setting, family meeting, assessment review, case conference, discharge meeting, review meeting, care planning, best interests meetings, and no doubt many more.
The characteristics of all these meetings are that they:
- concern one specific patient (not a group, as in a ward meeting)
- involve (or intend to involve) all members of the multi-disciplinary team, with or without other people from other services
- are convened to discuss some aspect of the person’s rehabilitation management to resolve it or make progress with it
- are usually planned themselves, albeit at short notice in some cases
- are expected to result in some actions
Formulation within the meeting
We must discuss the relationship with the formulation. Formulation by the team involved with a patient requires a meeting where team members can share information and interpretations, and analyses are debated and discussed. The formulation is the bedrock on which rehabilitation is built, and it is the bridge linking the problem and its assessment to the actions undertaken. Therefore it is not surprising that one meeting often encompasses both formulation and planning. Unfortunately, though some discussion of causes, prognosis etc., occurs, a traditional formulation is rarely reached and agreed upon. It happens because it must, but its importance is not acknowledged.
Thus, though it may seem more efficient to combine formulation with planning, there are risks:
- the time and attention needed to achieve a sound formulation are not allocated to the process
- the total time required for formulation and planning may be more than many people can give in a single stretch (and may exceed their attention span)
- if the time is fixed and limited, one or both processes will probably be incomplete or sub-standard, requiring a further meeting.
These risks only apply to the first-ever formulation. The team can quickly review and revise an existing formulation within a planning meeting but must do so at the beginning of the meeting.
For first-ever meetings, two solutions are possible. For most complex but not very difficult cases, a single session with an explicit agenda to cover formulation and planning, with a short break, would seem most appropriate. When a problem is more complex, a separate initial formulation meeting would seem justified.
Who should be present?
A further issue needs discussion – should the patient and family be present? The short answer is, ‘it depends’!
The patient must be the central focus of the meeting, and the professionals at the meeting must consider and respect the patient’s views and opinions. The patient (and/or family) do not need to be present, but everyone present needs to acknowledge and respect the patient’s perspective. The arguments on each side, supporting the presence of the patient and family and against having the patient and family present, are relatively obvious. I show a selection of the arguments below:
- Ensures patient views are heard (but not necessarily respected);
- The patient can gain much information about and insight into their situation and plan;
- The patient can give additional information;
- The patient can raise questions and can answer questions.
- It is usually stressful for the patient, especially in large meetings;
- People present may not express opinions or plans clearly, trying to avoid upsetting the patient;
- The meeting usually takes longer and can get deviated from its purpose (e.g. counselling the patient);
- People do not respect the patient.
The remainder of this page covers all rehabilitation meetings, not just so-called goal-planning meetings. It assumes that a core rehabilitation team is present and that other people may also be involved in the conference.
Reason for meeting
Planning meetings should always be convened for a reason. It is not appropriate to call a meeting ‘as a routine’, even if it is usually appropriate to have a review at a particular point in the patient’s journey. Meetings consume many resources.
Meetings will differ in their context: early after admission from a trauma ward; end of elective hospital admission; an outpatient with long-standing problems where a crisis has arrived; someone left too dependent and ill to return home and no longer needing rehabilitation; an acute illness has altered the prognosis; and so on. Each context will lead to different reasons for or expected outcomes from the meeting, even though the purpose will almost always include making decisions about future actions and drawing up plans.
Every meeting should start with a discussion and agreement about the main reason for the meeting and what other purposes it may be fulfilling. Therefore, the meeting should always begin by setting it in context, leading to the outcomes expected from the meeting. This part of the meeting often reveals disparate expectations from different people attending. Discovering this at the beginning allows discussion and clarification, making the meeting more productive.
The second crucial preparatory phase is to review the formulation. Often the formulation has only been made recently, and the review can be brief, but if this planning meeting is a later one, the team should review:
- clinical events or changes
- landmarks achieved
- further information from people attending, not known beforehand.
After reviewing and discussing any new evidence, the team should revise the formulation if necessary. It should be restated to ensure that it is understood, agreed and as comprehensive as needed.
Long-term, superordinate goals
Commonly, when faced with a complex problem, people identify some small component and start to resolve it without any analysis of the whole situation and how they will resolve it. Even after studying, many people still focus on the solutions to immediate problems. This approach risks failure, even harm, and is rarely efficient. One of the essential characteristics of a person or team that succeeds in solving complex problems is the early identification of an appropriate long-term goal.
Thus one of the attributes of an outstanding rehabilitation team is that it always considers the patient’s long-term outcome. At the same time, it is always person-centred focussing on understanding and basing plans on a patient’s priorities. To succeed, the team needs to:
- know what is vital to the patient in the long-term
- identify what outcomes are feasible and what can not be achieved
- negotiate with the patient a goal or goals that are:
- concordant with their priorities
- potentially achievable
- agree with the patient that the plans will be reviewed and revised in light of progress.
Thus, when the team has set a long-term aim at an earlier meeting, it should review the aim in light of any formulation revision and any new information about the patient’s wishes and priorities.
The long-term aims are likely to concern matters such as:
- Accommodation. Where will they live? Who else will be there?
- Social networks. How are they going to be supported socially? What opportunities will there be to maintain existing or develop new networks?
- Social interaction. Who will they be in contact with? Friends? Relatives? Colleagues? Note that loneliness is prevalent (here) and should be avoided.
- Social autonomy. Will they have much freedom and or ability to choose or control whom they interact with?
- Experience. How much pleasure and satisfaction might they have? Will pain and distress be minimised?
Long-term aims are necessarily uncertain and often aspirational. Despite this, they should be specific to the individual as far as possible. For example, not “To return to living in the community in an adapted house” but “To live in or as close to Ducklington as possible, so that his mother can visit easily and his daughter can provide support, and with a garden, so he can keep his dog as a pet.”
Sometimes, a patient steadfastly maintains a social role or position that is impossible as their principal goal. For example, a person who has an epileptic seizure after a traumatic brain injury with a depressed skull fracture could never return to being a pilot, regardless of complete recovery in all other areas. Or, more commonly, someone may never return to their previous life of moving around the country for work or living with their girlfriend.
This inability has several consequences. It may lead to a lack of engagement with rehabilitation and withdrawal. It will often cause distress, anger or depression or both. It may lead to trying dangerous and/or expensive ‘treatments’ (e.g. stem-cell injections) that will not succeed in helping.
Various strategies can be tried: allowing someone to learn through failure; continuing to give information and explanation; talking with family members to engage them; waiting. One more positive approach is to think of and offer an attractive alternative; for example, instead of striving to return to being a club champion golfer, taking up competitive wheelchair basketball.
Somehow or other, the team need to help the patient accept that there is a limit to what they can achieve, such that they can no longer perform previously essential activities. This goal adjustment needs to run alongside giving help to identify something that could or will become equally important. Not easy!
This is the part most professionals in a meeting feel most comfortable with – discussing what the team can achieve with the patient within a foreseeable time frame and then setting goals to improve performance at the level of activities. They are also the goals that the patient and family feel comfortable with. At least one reason for this is that discussing short-term (weeks) benefits can be used to avoid discussing or thinking about longer-term plans; it puts off difficult choices.
Although they are, obviously, closely intertwined, there are two distinct steps: considering what could be done and achieved and then deciding what should be done. The determinants are the patient-centred longer-term goals, which reflect the patient’s wishes and priorities. In principle, the discussion should specify all plans needed to achieve the long-term goals; the team can discuss other plans provided they are congruent with the patient’s wishes and do not interfere with accomplishing the critical objectives.
As is indicated in the accompanying graphic, the plan can accomplish change in several ways:
- capitalising on natural recovery from tissue damage or dysfunction;
- learning how to achieve old goals in new ways, for example, using a wheelchair to go around the shops rather than walking, or showering rather than bathing;
- adapting the environment and using equipment such as grab rails;
All three ways involve practice and learning by the patient, which is one of the main reasons for ensuring that medium-term goals are linked to long-term goals that are important to the patient.
Short-term, immediate goals.
Rehabilitation is usually a succession of particular actions covering many different things, from injecting botulinum toxin to getting a new bathroom built, adjusting a walking frame’s height, sorting out a care package, etc. Large projects use Gantt charts, but the number and complexity of actions in a rehabilitation plan are too great for these to be sensible. Collaborative planning and execution of activities are quicker. The equivalent of a Gantt chart in planning rehabilitation is to detail a set of particular actions, attributing each one to a named individual with an expected date or time frame.
The team cannot and does not need to plan every action required; the crucial steps to specify are those essential for progress. I illustrate the importance of identifying critical steps in a case from my early days in rehabilitation planning below.
At a planning meeting about an 18-year-old woman who wanted to live away from her mother, we agreed that the social worker would start identifying council (state) accommodation for her. We held weekly reviews of all inpatients, usually brief, and we had not specified the action so did not ask about it.
Six weeks later, when she was ready to move out of the hospital, we met to plan discharge. When asked about the accommodation, the social worker announced that she had not done anything “because the patient’s mother wants her to return to her [the mother’s] house.” We had a further discussion among the team and agreed again that the patient would be safe and that her wish to leave home was competent and fully informed.
If we had identified the action of finding accommodation as an essential action, we would have noticed the failure to progress much earlier. [This case also raised questions about our team communication and functioning because the social worker had not indicated any disagreement at the first meeting.]
A second set is immediate actions that depend, one upon the other. The coordination between different people needed must be discussed at the time, if possible. Most other activities do not require specific discussion or documentation.
Documenting the meeting
Documenting the rehabilitation process is, in my (limited) experience, poor and the Achilles Heel of many services. The document notes who attended the meeting but little else; it does not state the goals set or who is responsible for an activity. Occasionally, I have seen minutes recording who said what but not the conclusions reached.
A well set out, useful and informative record will:
- record date and time, who attended (names and roles), and the reason for the meeting
- a summary of the formulation, with reference to a formulation document
- set out the primary reason and the issues considered
- record the long-term goals or expectations
- if not done, recording why not
- outlining the reasons behind the goals briefly
- record the medium-term goals
- for each giving expected outcome and time frame, with an estimate of the likelihood of success
- record the short-term actions
- specifying what, who, why, and when
- specify the next meeting
- the date/time/place, or
- how this will be determined, or
- that there is no meeting expected
- record who will receive a copy of the document
- name the person responsible for the document and how to make contact.
One of the weaknesses in rehabilitation is that no one in the team takes responsibility for clear team-based documentation. Each person and profession will keep records of their day-to-day activities, input into the meeting, and what they need to do.
This piecemeal approach to documentation means that, sometime later, it is challenging to discover what the overall formulation or plan was. Importantly, it negates half the value of the meeting because people overlook some agreed actions, individuals ‘forget’ what they had to do or when, and coordination is lost. The chair or leader of the meeting must take responsibility for specifying explicitly who will provide a complete summary of the critical content of the discussion and should do this at the beginning of the meeting. It must be a clinician. The document must be a synthesis of the content of the meeting; it should not be a record of who said what.
The two key processes that determine whether rehabilitation will be efficient and effective are complete formulation and comprehensive planning. The formulation page and this page have dissected the processes involved to identify what is needed. Within experienced teams, many of these processes occur together. The critical skill required by the chair and others is to make sure that, even if hidden or done quickly, the many components of each process are present. Nothing in these two pages will surprise (I hope) people undertaking rehabilitation. The intention has been to show and discuss each component so that the team attends to each one. Details on setting goals can be found here and will be discussed elsewhere on this site soon.