The power of goals in community aged care

Are we accidentally making OT look like a one-visit service?

When I talk to OTs wanting to expand their community work into dementia, low vision, palliative care, restorative care and positive behavioural support - the same problem keeps coming up:

How do we get care partners and case managers to see the value of OT beyond a one-off assessment and equipment recommendation?

A recent survey I sent to OTs attending our dementia session reinforced this.

One OT wrote:

"Buy in from caregivers regarding interventions to support independence. Often they are burnt out and the referral to us is too late."

Another said:

"Getting families and case managers on board with ongoing therapy sessions. It's often recommended within the OT Initial Ax, but equipment/home mods always takes precedence."

These comments made me reflect on something much more fundamental than referral pathways or funding.

How are we communicating what we're actually trying to achieve through OT?

When the OT intervention isn't straightforward

In community aged care, OTs incredibly good at getting a lot done in a single visit.

Within 90 minutes, an OT might assess:

• functional mobility

• personal care

• transfers

• falls risk

• cognition

• the home environment

• equipment

• home modifications

• carer concerns

• and a range of other issues identified in the referral.

Then we produce a series of recommendations.

And often, that's exactly what is needed.

If someone is at risk of falling in the shower and needs a wall-mounted grab rail,

the clinical pathway can be relatively straightforward:

Problem → assessment → recommendation → intervention.

But what happens when the problem isn't that clean?

The person has dementia.

Their carer is exhausted.

They have stopped participating in activities they previously enjoyed.

There are changes in cognition, function, routines and behaviour.

The environment needs adapting, but so does the way the activity is approached.

The carer needs coaching.

And one 90-minute visit isn't going to address all of that.

Perhaps, in these situations, an "initial assessment" is actually more of a screen.

It identifies that there is something more complex going on.

And that's where I think we need to change the way we communicate the OT intervention.

The problem with documenting recommendations

If the documentation then becomes:

Issue identified. Recommend ongoing OT.

we've identified the problem, but we haven't made the intervention particularly visible.

The same happens when a series of visits is documented as:

Four sessions completed. Carer education provided. Equipment installed. Strategies discussed.

All of those things may be clinically appropriate.

But what was OT actually trying to achieve?

What changed?

Why did it require four sessions rather than one?

What was the role of the OT beyond identifying the equipment?

The clinical reasoning may be obvious to the OT who delivered the intervention.

But it isn't necessarily obvious to the person reading the report.

And this matters.

Because if the documentation makes OT look like assessment + recommendations + equipment, it is very easy for everyone around us to understand OT as a one-visit service.

The equipment is tangible.

The grab rail is visible.

The shower chair arrives.

The home modification gets installed.

The clinical intervention can be much harder to see.

Goals can make the intervention visible

This is why I've been thinking about goals.

Not simply because we're supposed to have them.

But because a well-constructed goal can communicate much more than an outcome. It can show the clinical pathway.

For example:

Mr X will participate in one meaningful daily activity matched to his interests and preserved abilities within 5 weeks, through 4 OT sessions using COPE-informed activity and environmental modification, life story work and carer coaching.

There's a lot happening in that one statement.

We know:

What matters: Participation in a meaningful daily activity.

What we're trying to achieve: Mr X participating in that activity.

When we'll review it: Five weeks.

Why ongoing OT is required: This isn't simply a recommendation. There is an intervention that needs to be implemented and reviewed.

What the intervention involves: COPE-informed approaches, activity and environmental modification, life story work and carer coaching.

How much OT is planned: Four sessions.

That is a very different proposition from:

Recommend ongoing OT to support dementia-related functional decline.

The first describes an OT program.

The second describes a recommendation.

Goals can tell the story of the intervention

I think this is where goals become particularly powerful.

A goal can create a narrative:

Baseline → Goal → Intervention → Review → Outcome

The baseline tells us where the person is now.

The goal tells us where we're trying to get to.

The intervention tells us what we're actually doing about it.

The review tells us what changed.

And importantly, the outcome doesn't have to be "independence."

Dementia

Mr X will participate in one meaningful daily activity matched to his interests and preserved abilities within 5 weeks, through 4 OT sessions using COPE-informed activity and environmental modification, life story work and carer coaching.

Low vision

Mrs X will prepare her preferred breakfast routine with no more than minimal assistance within 5 weeks, through 4 OT sessions using task analysis, environmental modification, low-vision strategies and graded practice.

Restorative care

Mr X will complete his usual shower routine with supervision rather than hands-on assistance within 6 weeks, through 5 OT sessions using task-specific practice, graded activity, equipment optimisation and carer coaching.

Palliative care

Mrs X will continue participating in her preferred gardening activity for up to 20 minutes over the next 4 weeks, through 3 OT sessions using energy conservation, positioning, environmental adaptation and activity modification.

Notice that the goal isn't simply describing an outcome.

It is showing why there is an intervention, what that intervention involves and why it needs time.

And this is particularly important in dementia

Success isn't necessarily restoring a lost function.

It might be maintaining participation.

Preserving a familiar routine.

Using retained abilities.

Reducing the amount of prompting required.

Supporting a carer to facilitate participation.

Adapting an activity as abilities change.

Reducing distress associated with a task.

Enabling someone to continue doing something meaningful.

Without a clearly defined goal, these outcomes can be almost invisible.

For example:

Mr X continues to spend time in the garden with support.

It sounds like nothing has changed.

But if the goal was for Mr X to participate in one meaningful daily activity within five weeks, and OT implemented COPE-informed strategies, environmental modification, activity scheduling and carer coaching to achieve that, then maintaining that participation is an OT outcome.

The intervention has a purpose.

The outcome can be reviewed.

And the value of the OT input becomes much easier to demonstrate.

This isn't just about better documentation

I don't think the answer is simply that OTs need to write better reports.

The bigger issue is that we need to make the clinical intervention visible.

If we want to move beyond the perception that OT is primarily about equipment and home modifications, our documentation needs to show what happens beyond the equipment.

The analysis.

The adaptation.

The graded practice.

The environmental changes.

The coaching.

The implementation.

The review.

The outcome.

Because we can't just tell case managers, care partners and funders that OT is more than equipment.

Our documentation needs to demonstrate it.

The question isn't just "what does the evidence support?"

This is particularly relevant when working with people living with dementia.

We can identify evidence-based approaches.

We can explain why a particular intervention is appropriate.

But evidence alone doesn't solve the practical barriers.

There's still a carer who is exhausted.

A case manager who may expect a one-off assessment.

A referral that arrives late.

A limited budget.

Competing priorities.

And a system in which equipment and home modifications are often easier to understand than therapeutic intervention.

So perhaps the challenge isn't simply knowing what the evidence supports.

It's being able to translate that evidence into a clear, goal-directed OT intervention that people around the client can understand and support.

That's the practice reality.

And it's one of the things we are unpacking in our upcoming webinar, with Senior Occupational Therapist and Director of Specialist Memory Services, Laine Bradley.

Not just what the evidence says.

But how we actually make evidence-based OT possible and visible in the real world.