This page considers meetings convened to plan rehabilitation, not the planning of meetings! In the overview of rehabilitation, there is a page concerned with ‘rehabilitation planning’. (here) That page covered formulation as well as planning, and was a brief introduction. Formulation was considered on the previous page in this section. (here) This page focuses much more on the planning aspect, giving more detail. It covers, briefly, some aspects of running a meeting. Planning meetings are often focused on ‘patient-centred goal setting’, and specific aspects of setting goals are only covered briefly here. More detail on goal setting will be given in the next page of this section. This is a long page: an outline is available in the MindMap available here.
Preamble and context
Not all rehabilitation is complex, requiring the involvement of a full team. In straightforward cases, it is reasonable for a single clinician to provide the rehabilitation, with two conditions attached:
- the clinician involved is part of a multidisciplinary team, and has unfettered and, if necessary, rapid access to other team disciplines;
- the clinician involved has expertise in rehabilitation, in addition to their professional expertise, so that the have the ability to recognise when other team members are needed.
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, and thereby the risk of patient harm.
The natural solution to the risk of waste and harm is for all those involved to meet, both to achieve a better understanding through the process of formulation, previously described, and to achieve a coherent and organised plan with coordination and sharing of activities. This page considers these meetings.
Name for meeting.
These meetings go by many names. For example the following names 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 with the intention of resolving it or making progress with it
- are usually planned themselves, albeit at short notice in some cases
- are expect to result in some actions
The relationship with formulation must be discussed. Formulation by the team involved with a patient inevitably requires a meeting where information can be shared, and interpretations and analyses debated and discussed. As has been emphasised, 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, it is rare that a formal formulation is reached and agreed. 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 is not allocated to the process
- the total time needed 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, it is probably that one, or both of the processes will be incomplete or sub-standard, requiring a further meeting.
These risks really only apply to the first-ever formulation. Once a formulation has been undertaken, then a review and revision of an existing formulation can easily be fitted in. Nonetheless, it must be done, explicitly, at the beginning of the meeting.
For first-ever meetings, two solutions are possible. For the majority of complex, but not very complex cases, a single meeting which has an explicit agenda to cover formulation and planning, with a short break, would seem most appropriate. When a problem is obviously more complex, a separate initial formulation meeting would seem justified.
Who is 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 patient’s views and opinions must be considered and respected at all times. This does not require the patient (and/or family) to be present. It does require all people present to acknowledge and respect the patient’s perspective. The arguments on each side are fairly obvious, and a selection are shown 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, especially in large meetings;
- People present may not express opinions or plans clearly, 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 there is a core rehabilitation team present, and that other people may well also be involved in the meeting.
Reason and review.
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 meeting at a particular point in the patient’s journey. Meetings consume much resource.
The reason will almost always include making decisions about future actions, and drawing up plans, but this is not sufficiently specific. Meetings will, however, differ in their context: early after admission from a trauma ward; end of an elective admission to hospital; 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.
The meeting should therefore always start by setting it in context, and giving the reason for the meeting and what it should achieve.
The second important preparatory phase is to review the formulation, which involves considering any events that have happened, or landmarks that have been achieved; any new information from changes seen over the integral since the last formulation; and any new information from people attending from other services that may not have been known beforehand.
The new formulation should then be restated to ensure that it is understood, agreed and as comprehensive as needed.
The primary purpose of this stage is to take all that is known about the patient (who may be present to ensure this happens) and to set some longer-term aim that is both consistent with their “past and present wishes, .. beliefs and values, … and any other factors … that they would consider“. [This comes from the Mental Capacity Act, and is as good a summary as any other.] Further discussion about ascertaining this information is given in the next page, which covers goal-setting.
If a long-term aim has been set at an earlier meeting, then this should be reviewed in the light of, first, any revision of the formulation and also, second, any new information about the patients own wishes.
The aims are likely to concern and be influenced by matters such as:
- Accommodation. Where will he or she 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 if possible.
- 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, as far as it is possible they should be specific to the individual. 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.”
Stage 2a; goal adjustment
Sometimes a patient steadfastly maintains as their predominant goal a social role or position that is simply not possible. 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, however complete all other areas of recovery are. Or, more commonly, someone may never return to their previous life of moving around the country for work, or to living with their girl-friend.
This inability has several consequences. It may lead to a lack of any 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 giving 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 can be achieved, such that previously important activities can no longer be carried out. This need to run alongside giving help to identify something that could or will become equally important. Not easy!
Activities & medium-term goals.
This is the part most participants feel most comfortable with – discussing what can be achieved within the service concerned and within a foreseeable time-frame, and then setting goals for the improvement of performance at the level of activities. They are also something the patient and family feel comfortable with. At least one reason for this is that discussing short-term (weeks) benefit can be used to avoid discussing or thinking abbout 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 are reflective of the patients wishes and priorities. In principle, all the goals needed to achieve the long-term goals must be included included; other goals can be set provided they are also congruent with the patient’s wishes and do not interfere with the important goals being achieved.
As is indicated in the accompanying graphic, the change may be achieved in several ways:
- capitalising of 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.
Rehabilitation is usually a succession of particular actions covering a multitude of different things from injecting botulinum toxin to getting a new bathroom built, from adjusting a walking frame’s height to sorting out a care package, and so on. Large projects use Gantt charts, but the number and complexity of a rehabilitation plan is to great for these to be sensible. Collaborative planning and execution of actions is 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.
Not every action can or should be planned. One set of specified actions is the key actions that must be done and/or markers that a series of key actions is underway or ended, and easily easily identified as completed. A second set is actions that depend, one upon the other. The coordination needs to be made explicit at the time, if possible. Other actions can be given, but it is better to focus on important ones only.
Document and distribute
Documenting the process of rehabilitation is, in my (limited) experience, very poor and the Achilles Heel of many services. The fact of a meeting is often documented, but recording matters such as the goals set, or who is supposed to do what is often recorded incompletely if at all. Occasionally, I have seen minuted meetings but these are also not helpful, being taken by a non-clinician who just records who said what but seems to skim over the important conclusions reached.
A well set out, useful and informative record will:
- record date and time, who attended (names and roles), and reason for the meeting
- a brief 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, saying why not
- outlining briefly the reasons behind the goals
- record the medium term goals
- for each giving expected outcome and time-frame, with an estimate of likelihood of success
- record the short-term actions
- specifying what, who, why, and when
- specify about 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 and of their input into the meeting, and what they need to do. This means that, some time later, it is very difficult to review what the overall formulation or plan was. Importantly, it negates half the value of the meeting, because actions are overlooked, 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 full summary of the important content of the meeting, and this needs to be done at the beginning of the meeting. It must be a clinician. The document is synthesised from the meeting; it is not a record of who said what.
The two key processes that determine whether or not rehabilitation will be both efficient and effective are a full formulation and productive planning. The formulation page and this page have dissected the processes involved to identify what is needed. In an experienced teams, many of these processes occur together, and they will not be ordered to obviously. The key skill needed 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 be a surprise (I hope) to people undertaking rehabilitation. The intention has been to show and discuss each component so that it always receives attention.