UCLA

Objectives

To develop a process of goal-setting and measurement of goal attainment in a dementia care management program.

Design

Observational.

Setting

Dementia care management program in an urban academic medical center.

Participants

Persons with dementia (N=101) and their caregivers; nurse practitioner dementia care managers (N=5).

Intervention

Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit.

Measurements

Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers.

Results

Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met.

Conclusion

Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain person-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care. J Am Geriatr Soc 66:2120-2127, 2018.