Authors (including presenting author) :
Yuen WM (1), Li HY(1), Yu Victor(2), Chan YK(1), Chan TS(1), Kong HL(1), Lin KL(1), Wong Stephen(2), Chan YP(2), Mak Flora(1), Lo Eva(2), Kng Carolyn(1)
Affiliation :
(1) Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospital
(2) Department of Medicine, Pamela Youde Nethersole Eastern Hospital
Introduction :
Dementia Community Support Scheme (DCSS) was a medical-social collaboration program to enhance the community support services for PWD and their caregivers. Pilot evaluation showed there was certain discrepancy between user expectation and the service provision. The discrepancy called for further action in learning individual needs which was important to PWD. Goal Attainment Scaling (GAS) helped to capture individual goals and to evaluate the outcomes as a quantity measurement.
Objectives :
This study aimed to examine the feasibility in application of GAS and to explore the expectations from PWD and their caregivers.
Methodology :
By referencing to the Light Model of GAS from the North West London Hospitals, DCSS Advanced Practice Nurse (APN) developed a process of goal setting and the outcomes measurement on goal achievement to review the program effectiveness. Target participants and their relatives were invited to have an in-depth interview and were encouraged to show their personal expectation towards DCSS. APN was responsible to facilitate SMART (Specific-Measureable-Attainable-Relevant-Time based) goal setting with clients through open discussion.
Result & Outcome :
359 PWD were recruited and set goal. Five main categories of goal were identified, majority of participants showed great concern on preserving cognitive function (61%). 30% would like to enhance social engagement, 6% of participants wished to maintain physical functioning in order to continue living at home. Minority of goals initiated by caregivers hoped to modify PWD’s challenging behaviors (0.6%) and some caregivers targeted to improve PWD’s mood through DCSS activity (2%).
Among them, 318 cases had completed the training and 310 rated their goal attainment. 82.3% of participants showed positive gain in the scoring which representing successful goal achievement. 11.1% had no change after training and 6.6% of participants reported of worsening. APN had encountered the difficulty in setting realistic goal with PWD. Some of their wish could not put into action and some goals were too far away from their ability. APN was required to manage their expectation and guide them in setting SMART goal.
Learning of individual goal for care could facilitate better patient-centre care planning which focus on their personal needs.
