The concept of goal setting in rehabilitation started with research and theory development in industrial/organizational psychology, specifically, goal-setting theory that was proposed by Locke and applied to rehabilitation by Schut and Stam.5 Locke theorized that the act of goal setting led to better task performance by streamlining efforts towards a specific endpoint. This work led to the development of “SMART” criteria to assist teams to set goals.
One interpretation of the SMART acronym, set forth by Schut and Stam is “specified, motivating, attainable, rational, and timed,” although there are a number of variations.6 (See Table 1, above.) Importantly, in relating the benefits of successful goal setting to rehabilitation, Schut and Stam emphasized that clinicians should carefully monitor the relative value assessment of the goals from both the clinician and client perspective and cautioned that goals need to be of value to the client.
When successful, motivational interviewing elicits a positive response that is rewarding for both the client and the clinician while increasing motivation to continue to strive towards goals and cementing a therapeutic relationship in the process.
Goal Setting
The perceived benefits of setting goals are numerous for clients and their rehabilitation teams. A discussion of goals allows the client to get feedback from the clinician about his or her status and clinical recommendations for treatment. Clients are afforded the opportunity to relate and prioritize which goals are most valued and intrinsically motivating. The goal-setting process allows clinicians to focus therapeutic efforts toward a specific outcome and to communicate targeted outcomes with the interdisciplinary team. Goals also create an objective standard to monitor and report client progress, which in turn provides documentation of improvement and support for third-party payers for reimbursement of continued services. Rehabilitation teams use SMART goal principles to systematically document medical necessity and to report progress so that the clients continue to receive the services that can provide benefit.
Conflicts may emerge, however, and clinicians may find themselves walking a fine line between true client-centered philosophy and the practical need to document medical necessity for reimbursement. In a recent analysis of documentation practice and rehabilitation, Granger and colleagues noted that the method in which “medical necessity is documented is crucial” and “insufficient documentation leaves the facility vulnerable to denied claims.”7 Providing sufficient clinical documentation of medical necessity may result in goal setting that does not truly reflect the client’s primary concerns or that may be worded in ways the client does not understand. Clinicians run the risk of setting clinical goals that clients find irrelevant or that conflict with competing priorities. This situation may ultimately decrease client engagement with therapy and lead to poorer functional outcomes and lower client satisfaction.8
