Person centred goals are an integral component of health services including Transition Care Program (TCP). The TCP is a National service designed as a restorative program for older adults after an acute, inpatient hospital episode, allowing additional time to finalise longer term care arrangements.  The “time-limited, goal-oriented and therapy-focused” program (TCP guidelines, 2014, p 5) aims to improve an individual’s ability through enhancing physical, cognitive and psychosocial functioning by means of restorative processes, personal care and case management. The program’s objectives are to avoid recurrent re-admissions to hospital, support eventual discharge home, and avoid residential care placement.

This research project explored the effectiveness of goal communication between the clients and staff in TCP. It aimed to identify how clients understand and are engaged in goal activities by exploring their perceptions and experiences of goals through semi-structured interviews at three time points: admission to, discharge from and three months after discharge from TCP. The experiences, perceptions and views of the clinical staff working with the clients were investigated through focus groups.

Results showed that all clients and staff agreed on the unspoken primary goal as ‘aiming for home’, regardless of physical, emotional or social status, or stated goals on admission. Clients’ relationship with ‘home’ changed at the different time points, particularly for those clients discharged to a new home of residential care.

The second consistent theme to emerge for clients was ‘return to normal’ and how this was linked to their sense of identity, self-efficacy and self-confidence. ‘Return to normal’ was not possible for many of the clients and their experiences of adjusting to a ‘new normal’ were explored.

The language of ‘normal’ was never identified by staff who had a different interpretation and talked in the language of ‘recovery’ with a focus on function that was not always clear to clients. Clients found staff both encouraging and supportive in functional daily activities but did not relate these activities to their goals. Staff integrated daily functional activities into measures of progress and discharge planning. However, the activities were not named explicitly as ‘goals’, so the clients could not see the relevance of daily activities to their goals and did not believe they had had conversations about goals with the staff.

Clients talked of the support they received throughout their stay in TCP, which manifested differently at the three time points: at admission, care was the priority and provided by the staff; at discharge, support was identified through services arranged to go home, generally initiated by staff in close liaison with clients and their families; three months after discharge support was revealed in the social reintegration with society and community which was generally self-generated by the clients.

The biggest barrier for clients was fatigue, which affected them physically, mentally and emotionally. Fatigue reduced the ability to think coherently, take on new information, participate in the restorative therapy or plan for the future. The ability to adjust to change correlates with overall life satisfaction (Bailly et al., 2014). The object of change differed between participants and may have included loss of identity, functional independence, driving capacity or ability to live at home. The impact of grief and the additional psychological and emotional effects of fatigue may explain why this population found dealing with change so difficult.

Policy implications for this research are that clients’ goal attainment in the TCP is linked with the program KPIs of discharge destination, length of stay, bed occupancy, readmission to acute hospital and functional status to evaluate the program’s effectiveness in functional restoration in a more objective manner and therefore identify the relationship between goal attainment and TCP effectiveness.

Clinical recommendations to come from this research include using consistent goal language, introduced on admission and kept consistent throughout the TCP stay. A second recommendation is to challenge staff acceptance of what an ‘acceptable’ or ‘attainable’ goal may be, to consider those client goals that are beyond the remit of the service. This would enhance client motivation, participation and engagement within the service and keep the client focussed on what is most important to them – going home and getting back to normal.

Nicky Baker completed this research to graduate in April 2019 as Master of Clinical Rehabilitation (Research), supervised by A/Prof Stacey George, Prof Sharon Lawn and Prof Sue Gordon.