The Value of Crafting Individualized Patient Goals



Author: Brian Taylor, Au.D.

Most audiologists conduct, at a minimum, some cursory goal setting with patients. For instance, the audiologist may ask about telephone use or communication in noisy listening situations. Very few audiologists, however, appear to have a systematic way of documenting how individuals are functioning and what strategies and/or technology they may be using over an entire range of daily activities. This is a lost opportunity to leverage relationship centered communication in the quest for optimal patient outcomes.

Perhaps the most critical component of the help seeking appointment is the audiologist’s ability to elicit comprehensive functional treatment goals that genuinely reflect the priorities of the individual. After all, it would be easy to assume the typical help seeking patient is challenged to communicate with grandchildren, on the phone, or in busy restaurants. Given the frequency of occurrence of these situations, the audiologist would not be wrong if they simply jotted down these common troublesome environments as places the help seekers wanted to improve with treatment. However, not taking the time to learn specifically where a help seeker is a lost opportunity. Let’s say, for example, the audiologist, with limited input from the help seeker, recorded three basic goals to improve with hearing aids, as listed:
  • Restaurants
  • Grandchildren
  • Television
Yes, the audiologist has targeted three situations for improvement, but because the goals are so vague and unspecific, it is difficult to gauge success or analyze, post treatment how to improve outcomes through counseling or adjustments to the hearing aid.

Once the patient, with input from their communication partner, starts to formulate where they want to experience improved communication, along with some of the emotions associated with not being able to effectively communicate because of their hearing loss, the provider can begin recording these targeted goals. Figure 1 is an example of the Patient Expectations Worksheet (PEW). It is used to formalize or record the patient’s targeted goals. Notice in Figure 1 two specific goals that have been recorded and the patient has rated, using a 1 to 5 scale, and how they communicate in that specific situation prior to treatment. Experience suggests that goal setting proceeds more smoothly when both a listening situation and an accompanying emotion associated with it are paired together.
Figure 1. An example of the completed Patient Expectations Worksheet where treatment goals are recorded. C = how patient rates their current ability to communicate, E = how the patient expects to communicate post-intervention


Expectations and Goals
According to Palmer and Cox (1999) expectations are what a patient believes will happen given a particular course of action. The expectation may be the actual level of success that one believes can be achieved with a particular intervention. In other words, a patient may believe that he will be successful most of the time if a particular course of action is taken and only successful half of the time if some other action is taken. Functional goals are created from realistic expectations, and require give and take from the audiologist, patient, and communication partner. When each party weighs in on the goal setting process, realistic expectations should translate directly into the goal setting process. The intervention or treatment plan is created directly from the goals that have been agreed upon by all parties, and success is measured by going back to the original expectation and evaluating how the individual is functioning. Let’s take a look at how this goal setting process unfolds during a help seeking appointment using the Patient’s Expectation Worksheet (PEW).
How to Create Collaborative Goals
The most effective goals require collaboration and reflect the real world demands of the person with hearing loss. Additionally, each goal should pair a specific listening situation targeted by the patient with an emotion that the patient wants to experience more of if it is a positive emotion (enjoyment) or less of if it is a negative emotion (frustration). Armed with these two pieces of critical information, the audiologist records collaborative goals along with patient expectations as part of an individualized treatment or intervention plan. A modified version of the Client-oriented Scale of Improvement (COSI), the PEW is where goals and expectations are recorded. The PEW allows the patient and audiologist to rate on a 1 to 5 scale four factors, corresponding with each targeted goal.

After two to five goals have been identified, the patient indicates how often he is successful in the situation currently (C), prior to intervention, and how he expects to function after the intervention (E). The audiologist marks the PEW with a check mark (“✓”) to indicate what she believes is a realistic expectation given the individual characteristics of the patient (audiologic and non-audiologic information). Recall that a fundamental principle of relationship centered communication is the patient is the expert on his condition and what to expect from intervention, but equally important, the audiologist is an expert on hearing disorders and the advantages and limitations of various interventions for each particular patient. Completing the PEW together is an example of the value of what each party, respectively, brings to the treatment planning process.

If the “E” and “✓” are not in agreement, the audiologist counsels the patient until he understands why the expectations were either high or low, or how the planned intervention ought to be modified to better meet the expectations of the patient. Interventions are planned based on the identified goals and the audiologist creates ways to measure each functional goal. Figure 2 shows an example of a completed PEW in which the patient’s expectations and the audiologist’s judgments of success are in alignment. To illustrate this point, let’s say the patient in this example has an unaided Quick SIN score of 5 dB SNR loss in each ear and recognizes he has a significant hearing loss and it highly motivated to receive help from the audiologist. Note in Figure 2 the audiologist has applied this information in her judgment of expectations for this patient. When the audiologist and patient are in alignment on goals and expectations, an optimistic outlook of patient outcomes can be communicated by the audiologist. Given the results in Figure 2, the audiologists might say something like this to the patient, “If we work together….I will teach you all you need to know and make sure the hearing aids are fitting properly and if you follow my directions, we have a good chance of achieving these goals.”
Figure 2. An example of the completed Patient Expectations Worksheet where treatment goals, expectations are recorded. Expectations of the patient are compared to how the audiologist believes the patient will be achieved post intervention. C = how patient rates their current ability to communicate, E = how the patient expects to communicate post-intervention, I = audiologist’s belief of what outcome the patient will achieve.


Contrast the example in Figure 2 with the example shown in Figure 3, in which there is misalignment between the patient’s expectations and the audiologist’s prognosis for successful outcomes. The example in Figure 3 shows the same goals and expectations as those in the previous example of Figure 2 with one major difference: Unaided Quick SIN score of 12 dB in each ear and patient who has been judged by the audiologist to be unmotivated to get help. Given this information, the audiologist is compelled to take one of two courses: Counsel the patient about lowering his expectations or offer a more rigorous treatment plan that may include the consistent use of Bluetooth-enabled remote microphone technology or comprehensive auditory training courses – both of which add complexity and cost to the intervention. In this case, as outlined in Figure 3, the audiologist may share with the patient the following message, “I am going to ask you to do something that may be outside your comfort zone……How do you feel about that? Based on what I am seeing you have two options: 1. I’d like you to re-think your expectations. They might be a little too high. or 2. I need to recommend an accessory to your hearing aids that will help you achieve your goals….this accessory will take some time to learn how to use and it will add to the cost. But it’s necessary to achieve the outcomes you wish for.”
Figure 3. A second example of the completed Patient Expectations Worksheet where treatment goals, expectations are recorded. Expectations of the patient are compared to how the audiologist believes the patient will be achieved post intervention. Note the misalignment. C = how patient rates their current ability to communicate, E = how the patient expects to communicate post-intervention, I = audiologist’s belief of what outcome the patient will achieve.
Acceptable vs. Ideal
The PEW is a useful example of how information, beyond the basic hearing test, can be readily gathered during a routine help seeking appointment, discussed by the audiologist and help seeker, and then turned into functional goals in a collaborative manner. When expectations are added to the goal setting process, the dialogue between the audiologist and help seeker is allowed to evolve into a discussion of what might be ideally achieved through treatment and what is realistic or acceptable. It is up to the audiologist, using their expertise along with the information gathered during the appointment, to lead a discussion on when expected outcomes might be less than ideal. Equipped with this knowledge, the help seeker must then decide to lower expectations or investigate other courses of action, such as using hearing aid accessories or additional auditory training exercises that might result in superior outcomes, but add complexity and expense. This is the type of honest and frank conversation that is an essential component of relationship centered communication and shared decision making. Recall, there are three essential pillars to shared decision-making: (1.) educating the help seeker on his condition and treatment option; (2.) identifying the values, preferences, and goals of the help seeker; and (3) collaboration to identify the most appropriate and individualized treatment plan. The PEW is a sort of canvas where this discussion and shared decision making occurs.
Figure 4. Legend: In this example of the completed PEW, the “I” designates final outcome on the 1-5 scale, one-month post intervention


Finally, the PEW can be used again post-intervention as an outcome measure, as illustrated in Figure 4. The patient marks the sheet with the letter “I” to indicate the level of success after the intervention. If the “I” does not match the original expectation, the audiologist re-examines both the expectation and the intervention and modifies the treatment plan as needed. For more details on how aligning goals and expectations using the PEW fit into clinical practice, see Palmer (2005).
Generating Specific and Targeted Treatment Goals
In addition to being specific and actionable, treatment goals need to be time-bound and collaborative. This means that the audiologist and patient agree to a timeframe for when goals should be achieved and what each party (audiologist and patient) will do to achieve each goal.

Finally, when collaborating on a set of goals, make sure the goals are functional in nature. That is, the goals need to reflect the communication experiences of the individual - where that person wants or needs to improve in their daily living.    
Brian Taylor, Au.D. is the editor of Audiology Practices. He is also Director of Clinical Content Development for WS Audiology.
References
Palmer, C. V., & Mormer, E. (1999). Goals and expectations of the hearing aid fitting. Trends in amplification, 4(2), 61–71.

Palmer C. V. (2005). Quantifying and responding to patient needs and expectations. Journal of the American Academy of Audiology, 16(10), 789–808.