Goals
- Nikhil Balasubramanyam (Deactivated)
While the [LINK-VISION PLANNING] section of UCCP allows the navigator or provider to develop a deeper understanding of the client’s individual needs and goals, the purpose of the Goals page is for the care coordinator or provider to create, manage and designate responsibility for the incremental steps that will lead to the completion of the client’s overall goals/aspirations. To open up the client’s Care Plan page, enter the client’s record or profile. From the navigation bar, click on the Goals tab (Figure G-1).
This page is broken down into 3 sections:
Goals
The Goals section of the Care Plan page lists all goals that have been identified for the client. This section answers the question of Who or what is important to the client? Users can filter the list of goals between Care Provider Defined Activity, a task the navigator to perform, Client Defined Goal, a goal for the client complete, or All results. In this section of the page, users will be able to 1) create new goals (G-2.2), 2) edit/ view existing goals (G-2.3) and 3) indicate goal that are shared with other members of their household (G-2.3). To indicate a shared goal, click the checkbox next to the intended goal (G-2.4) For more information on households click here: [LINK-HOUSEHOLD]
Adding a New Goal
To add a new goal, click on the + Add New Goal button (Figure G-2.1). The Client Goal window will pop up (Figure G-3). A barrier can be linked to this goal by selecting the barrier from the drop-down selection highlighted in Figure G-3.1. Then, click on the Create New Goal, or the Choose a Template Goal button (Figure G-3.2). Both paths are ways to create a goal, but the former will have empty fields (Figure G-4), whereas the latter will have certain fields already filled based on the Goal Category, and Goal selections, as shown in Figure G-5. A template goal will have all action steps already outlined (Figure G-6).
Goals and action steps added through Template Goals will always be marked as provider-defined activities for the client.
Adding a New Goal – Create New Goal
When creating a new goal, there are several fields to complete before the goal is added to the client’s care plan (Figure G-4). The parameters are detailed in the list below:
Goal Barrier- Use the drop-down menu to indicate the barrier the goal seeks to address
Goal Name – The name of the goal.
Social Determinant – Use the drop-down menu to choose which of the following 8 social determinants of health (SDoH) this goal is addressing: Health, Substance Order Abuse, Mental Health, Housing, Social Service, Education, Food, Economic Stability.
Goal Description – Use this free text box to provide additional details pertaining to the goal. This may include specific details that are not clear based on the other parameters listed.
Expected Start Date – Use the calendar icon button to indicate the expected start date for the initial process of achieving the goal.
Expected End Date – Use the calendar icon button to indicate the expected date of completion for this goal
Status – Use the drop-down selection to select the status of this goal. The four possible options are: Yet to Start, In Progress, Closed but Incomplete, Complete.
Incentives and Notes – Use the empty text box to write additional notes on this goal.
Action Steps – Click on the + Add New Action Step button (Figure G-4.1) to create an action step for this goal. Once this button is clicked, the fields right below (Action, Responsible Person, Description, Priority, Due Date, Status) will be open to input relevant information (Figure G-4.3). Click on the Cancel Changes button (Figure G-4.2) to cancel any changes made to an action step.
The following fields are also available to be edited, but will more likely be entered when editing the goal at a later date from when the goal was initially created.
Actual Start Date – Use the calendar icon button to indicate the actual date steps to complete this goal began.
Actual Completion Date – Use the calendar icon button to indicate the actual date this goal was completed. This field is only editable if the Status is set to Complete.
Completed By – Use the drop-down selection to choose which the care coordinator provider that created this goal. This field is only editable if the Status is set to Complete.
Shared Goal- Use the checkbox to indicate if this goal is shared with other members of the client’s household.
Once all fields have been completed, be sure to click on the Add button in Blue to finish adding the goal to the client’s care plan. Without clicking on the Add button, the goal will not be added to the client’s care plan.
Adding a New Goal – Choose a Template Goal
Choosing a template goal is best used in the instance of a care coordinator or provider creating a common goal for a client that has been pre-defined by their organization (e.g. find housing, gain employment, make appointment with primary care physician, etc.). When choosing a template goal, the following steps will need to be completed:
Goal Category (G-5.2) – Use the drop-down selection to choose from the pre-defined list of goal categories.
Goal Name (G-5.3) – Use the drop-down selection to choose a goal sub-category from a pre-defined list of Goal Names.
Once the selections have been made for Goal Category and the Goal Name, all fields outlined above (G-4) will be pre-populated.
Once all necessary and possible fields have been entered or updated, be sure to click on the Add button in Blue to complete adding this template goal to the client’s care plan.
Viewing/Editing a Goal
To see more details about a goal, click on the Pencil Icon under the Actions column (G-2.2). The Client Goal window will pop up. When making changes to a goal, be sure to click on the Update button (G-7.1).
If the goal being edited is from a new goal, then action steps can be added when editing the goal. If the goal being edited is from a template goal, then action steps cannot be added to the goal; only existing action steps can be edited. The screenshot below is from a new goal.
G-7: Viewing/Editing a Goal
Action Steps
The Action Steps section allows for users to create and manage incremental action steps that will be taken on the way to completing the client’s goals. This section answers the question of What needs to be done to accomplish each goal? (G-8).
From the grid, the current logged-in user can add, edit, view, or delete action steps. To view all action steps for a goal, click on the goal (this will highlight the goal Blue)- in the example shown above, the indicated action step pertains to the goal, “Transportation Needs for Medical Services” (G-8.1). To add a new action step for this goal, click on the + Add New Action Step button (G-8.2). To view or edit an existing action step for the selected goal, click on the Pencil Icon button (G-8.2). To delete a previously created action step for the selected goal, click the Red X icon under the Delete column of the action step.
Adding a New Action Step
Once the + Add New Action Step button has been clicked, the Client Action Step window will pop up (G-9).
Figure G-9: Adding a New Action Step
Fill in the possible fields, listed below:
Goal – This will be pre-populated with the name of the goal that was selected in the Care Plan page.
Action Step Type – Choose from the drop-down selection what type of action step is being added; for example, this action step is to perform a Client home visit. The selection available in this drop-down may differ depending on the current logged-in user’s organization’s set up of the platform.
Description – Add a description of the action step in the text-box.
Responsible – Choose whether the person responsible for this action step is the Client, the Staff, or Other.
Responsible (additional information) – If The Client is chosen from the previous field, this drop-down selection will not be accessible, as there is no need to clarify further. If Staff is selected in the previous field, expand the drop-down selection and choose the provider or care coordinator responsible for this action step. If Other is selected, type in the name of the person, or a description of the person who is responsible; for example, Client’s Sister.
Priority – Expand the drop-down selection and choose the priority of this action step: Optional, Optional but Recommended, Recommended, Highly Recommended, or Mandatory.
Due Date – Enter the due date for this action step in m/d/yyyy h:mm AM/PM format, or pick the date by clicking on the calendar icon button and pick the time by clicking on the clock icon button.
Status – Expand the drop-down selection and choose the status of this action step: Yet t Start, Done, or Not Applicable.
If the Status chosen is Done, the following fields can be editable:
Actual Completion Date – Enter the date this action step was completed in m/d/yyyy format, or pick the date by clicking on the calendar icon button.
Completed By – Expand the drop-down selection to choose who completed this action step.
Once all possible fields have been entered, be sure to click on the Add Action Step button (Figure G-9.1). Without clicking this button, this action step will not be added to the goal.
Viewing/Editing an Action Step
Once the Pencil Icon link has been clicked (G-8.3), the Client Action Step window will pop-up, allowing the current logged-in user to update details on a previously-made action step (G-10).
The Client Action Step window contains the same fields as those that appear when first creating the action step (G-9). Each field will function in the same way they were described. If the action step is being formally completed, select Done from the drop-down selection for Status. The Actual Completion Date field will be available to be edited. Enter the date this action step was completed in m/d/yyyy format, or pick the date by clicking on the calendar icon button. The Completed By field will also be available to be edited. Expand the drop-down selection to choose who completed this action step.
Be sure to click the Update Action Step button before closing the window, to ensure that the changes are saved (G-10.1). Without clicking this button, this action step will not be updated.
Interaction Information
The Interaction Information section of the client’s care plan allows for care coordinators or providers to see notes pertaining to each interaction between the client and the care coordinator/provider, whether in-person, virtual, or through the phone. This section answers the question of What was the purpose, and what happened during each visit with the client?
The following information is provided in this section:
About – This column briefly indicates the reason for the interaction.
Successes, Challenges – These two columns represent successes and challenges that occurred as a result of that particular interaction.
Performed By – This column indicates the person who interacted with the client.
On and Time Spent – This column represent the date, time, and duration of the interaction.
Figure G-11: Interaction Information