Improving access, efficiency and equity through family-centred goal setting: Good Goals intervention
Children's community rehabilitation services have highlighted difficulties in achieving acceptable waiting times and equitable service provision. It is plausible that these problems are partially a function of individual clinicians' caseload management (i.e. practices related to assessment, treatment provision and discharging).
Until this project, research about community professionals' caseload management has been scarce. Since 2006, we have been conducting a series of studies (i) to develop an intervention to improve (community-based) children's occupational therapists' caseload management, and (ii) to investigate the feasibility of using the intervention in practice.
The specific aim of the intervention is to improve the likelihood that children with similar needs receive similar care (consistency) and to improve clinicians' use of current resources (efficiency). Whilst the work to date has been within occupational therapy, it is expected that in the longer term, the intervention could be used to improve community clinicians' caseload management in general.
This research maps on the MRC framework for developing and evaluating complex interventions. To date, the following steps, and studies within them, have been completed:
1. Generate an evidence base of children's occupational therapists' caseload management and its current problems: (i) a systematic review, (ii) an interview study with occupational therapists, (iii) an interview study with parents, and (iv) analysis of children's case notes.
2. Build a theoretical model of therapists' caseload management behaviours: a synthesis of the above evidence and existing theory and evidence in behaviour change.
3. Design an evidence- and theory-based intervention to change therapists' caseload management: a collaborative study with occupational therapists and experts in behaviour change (i.e health psychologists).
4. Investigate the feasibility of using the intervention in practice: three mixed-methods case studies of children's occupational therapy services (n=46 therapists).
The intervention, titled Good Goals, targets three behaviours: identifying good quality goals; agreeing these goals with clients; and evaluating the client's progress toward the agreed goal. These are the behaviours which the evidence from step 1 indicated are related to efficient, good quality management of cases.
Good Goals consists of four clusters of clearly specified behaviour change techniques. The pathways through which these techniques are hypothesised to cause changes in the outcome are explicitly specified.
Good Goals is delivered over 25 weeks and through face-to-face training sessions, DVDs, practical group tasks, and therapist-led team meetings. Some aspects are delivered by a trained facilitator whilst others are self-administered by the therapists. The delivery follows an explicit manual.
The evidence from the step 4 feasibility study indicates that Good Goals may help therapists to have a shared rationale for clinical decisions and increased clarity in service provision. Intervention uptake amongst the pilot participants was generally good; the barriers to uptake included therapists working across several locations, working part-time or perceived lack of time. The total cost of Good Goals per service was estimated at between £8,206 (small service) and £33,027 (large service).
During the 25-week study period, therapists' performance of the three target behaviours increased: identifying goals, odds ratio 2.4 (95% CI 1.5 to 3.8); agreeing goals, 3.5 (2.4 to 5.1); evaluating progress, 2.0 (1.1 to 3.5). Longer follow-up is required to evaluate other outcomes (e.g. waiting times).
A formal evaluation is required to investigate the effectiveness and cost-effectiveness of Good Goals. We are currently preparing a funding application and identifying potentially interested services for this.
Niina Kolehmainen; firstname.lastname@example.org
Steps 1-4 have now been completed. Funding is currently sought to extend Good Goals beyond occupational therapy and to formally evaluate its effectiveness and cost-effectiveness. To keep up-to-date with the most recent developments please see www.facebook.com/goodgoals (by ‘liking’ Good Goals you will receive an alert every time news items are posted).
Step 1: Evidence about current caseload management and its problems
Kolehmainen N, Francis J, McKee L. To provide or not to provide treatment: that is the question British Journal of Occupational Therapy. 2008 71(12) 510-523
Kolehmainen N, Francis J, Duncan EAS, Fraser C. Community professionals’ management of client care: a mixed-methods systematic review Journal of Health Services Research & Policy. 2010 15(1) 47-55
Kolehmainen N, Duncan EAS, McKee L, Francis J. Mothers’ perceptions of their children’s occupational therapy processes: a qualitative interview study. British Journal of Occupational Therapy. 2010 73(5) 192-199
Kolehmainen N, MacLennan G, Francis J, Duncan EAS. Clinicians' caseload management behaviours as explanatory factors in patients' length of time on caseloads: a predictive multilevel study in paediatric community occupational therapy. BMC Health Services Research. 2010 10:249 doi:10.1186/1472-6963-10-249
Kolehmainen N, McKee L, Francis J, Duncan EAS. Beliefs about responsibilities, the aims of therapy, and the structure of the therapy process: a qualitative study of caseload management issues in child health occupational therapy. Child: Health, Care and Development. 2012 38(1) 108-116 doi:10.1111/j.1365-2214.2011.01220.x
Kolehmainen N, Duncan E AS, Francis J. Clinicians' actions associated with the successful patient care process: a content analysis of interviews with paediatric occupational therapists. Disability and Rehabilitation. 2013 35(5) pp.388-396 doi: 10.3109/09638288.2012.694960
Step 3: Design an evidence- and theory-based intervention
Kolehmainen, N. & Francis, JJ. (2012). 'Specifying content and mechanisms of change in interventions to change professionals’ practice: an illustration from the Good Goals study in occupational therapy'. Implementation Science, vol 7, pp. 100.
[Online] DOI: 10.1186/1748-5908-7-100
[Online] AURA: kolehmainen_2012.pdf
Step 4: Using the intervention in practice
Kolehmainen, N., Maclennan, G., Ternent, L., Duncan, EA., Duncan, EM., Ryan, SB., McKee, L. & Francis, JJ. (2012). 'Using shared goal setting to improve access and equity: a mixed methods study of the Good Goals intervention in children's occupational therapy'. Implementation Science, vol 7, pp. 76.
[Online] DOI: 10.1186/1748-5908-7-76