Exploring Goal-Setting and Achievement Within Reablement: A Comparative Case Study of Three Countries

Figures & data

Table 1 Background Information of Reablement Programs in Norway, New Zealand and the Netherlands

	Bergen (Norway)	Waikato (New Zealand)	Limburg (The Netherlands)
Reablement program since	Bergen-model of Everyday rehabilitation since 2015	START since 2010	I-MANAGE since 2022
Organization and funding^Citation13	Vague national guidance of implementation, provided by municipalities Free of charge	Integration into national home and community support services, provided by health regions Case-mix funding	No national guidance or coordination, provided by local healthcare organizations/municipalities Fee-per-hour or lump-sum funding
Target group	No lower age limit. Remain in their own home, experience functional decline and are not excluded based on a particular diagnosis	Lower age limit of ≥65 years (Māori ≥55 years). Remain in their own home, medically stable, at risk of (re)admission to the hospital or nursing home and are not excluded based on a particular diagnosis	No lower age limit. Remain in their own home, experience functional decline, can learn and apply new skills and are not excluded based on a particular diagnosis
Patient inflow and initial assessment	The municipality has a multidisciplinary assessment team that evaluates care services applications. Enrolment is also possible based on the request from others, healthcare professionals. COPM is used for the needs assessment and is conducted mostly by OT, PT, or RN	The multidisciplinary team actively “draws” patients to the Older Person’s Assessment Liaison (OPAL) service in the hospital, or enrolment through the Needs Assessor Service Coordinators (NASC) linked to the general practitioner. The needs assessment is conducted mostly by an RN, sometimes PT or OT using interRAI Home Care Assessment	After a referral from the GP or ECP, an introductory meeting is scheduled with the OT employed by an elderly care organizationIf eligible, the OT will conduct the needs assessment using the COPM and Positive Health Questionnaire
Duration	4 weeks	Up to 6 weeks	8 weeks

Abbreviations: RN, registered nurse; PT, physical therapist; OT, occupational therapist; GP, general practitioner; ECP, elder care physician; COPM, Canadian Occupational Performance Measurement;²⁷ TARGET, Towards Achieving Realistic Goal in Elders Tool;²⁸ InterRAI, Inter-Resident Assessment Instrument²⁹.

Table 2 Comparison of Goal-Oriented Approaches Within Reablement Programs

	Norway	New Zealand	The Netherlands
Goal-setting
Application and assessment	1. Preparation: Collecting and reviewing (medical) information regarding user	Similar to Norway, except for: Referral through hospital discharge service or charge nurse manager	Similar to Norway, except for: Assessment by OT and/or ECP
	2. Assessment visit Assessing eligibility and help request for reablement by two therapists	Assessment mostly by an RN, sometimes PT or OT
Identifying and prioritizing goals	3. Goal meeting: Setting goals with users using COPM semi-structured interview	Similar to Norway, except for: TARGET and goal ladder are used for goal-setting.	Similar to Norway, except for: Questionnaire Positive Health with COPM used for goal-setting, after goal meeting the next step includes observation of all relevant HCPs
	4. Observation (action meeting): Observing users in the activities relating to the goals.
Setting goals	5. Setting final reablement plan during the multidisciplinary team meeting- Going from sub-goals to overall goals and vice versa	Similar to Norway	Similar to Norway
Type of goals	Everyday activity and social goals	Similar to Norway	Similar to Norway
Evaluation and follow-up	Revising goals along the way Evaluation at: - Halfway - End of program Flexibility at end of program 1-month follow-up after end of program	Similar to Norway, except for: Weekly evaluations Follow-up at 3, 6, 9 and 12 months	Similar to Norway, except for: No structural follow-up

Abbreviations: OT, occupational therapist; ECP, elder care physician; HCP, healthcare professional; COPM, Canadian Occupational Performance Measurement;²⁷ TARGET, Towards Achieving Realistic Goal in Elders Tool.²⁸

Table 3 Comparison of Organizational Structures of Multidisciplinary Teams Within Reablement Programs

	Bergen (Norway)	Waikato (New Zealand)	Limburg (The Netherlands)
Roles and tasks
Professions within the reablement team	PT, OT, RN and NA. The team only works with reablement and does not have other tasks within primary care	Identical to Norway, except for: HCA instead of NA GP and ECP on a consulting basis	Identical to Norway, except for: NA is not involved, IC is standardly involved and GP and ECP on a consulting basis. The team delivers reablement as one of their tasks in primary care
Task distribution	Task shifting: Roles are assigned regardless of occupation and based on availability	Identical to Norway	Fixed tasks: Roles are assigned solely based on occupation
Roles	1) Home trainer, in charge of daily training Advocate for the user Usually NA 2) Coordinator, team supervision, communication, meeting initiation and leadership, handles operations and logistics Can be OT, PT, or RN 3) Therapists - First therapist: coordinates, in charge of goal conversation, evaluations and development of the rehabilitation plan, supervises and talks to the home trainer daily Can be OT, PT, or RN - Second therapist: primarily consults, and participates in relevant meetings as supervisor/expert Facilitates referrals and dialogues with external HCP Can be OT, PT, or RN	1) Home trainer, in charge of daily training Advocate for the user Usually UNA 2) Coordinator, in charge of goal conversation, rehabilitation plan, team supervision, meeting initiation and leadership, handles operations and logistics Usually RN 3) Therapists Provide weekly training related to the goals and supervise the home care staffCan be OT or PT 4) Physician GP or ECP provides medical treatment and supervision when needed	1) Occupational therapist Coordinator: in charge of goal conversation, user follow-ups, rehabilitation plan, supervision and communication with the team. Provides training and coaching related to the goals for HCP and informal carers when needed 2) Physical therapist Provides training and coaching related to the goals for HCP and informal carers when needed 3) Registered nurse Combines direct care with coordination for home care staff 4) Informal care consultant Works with informal caregivers to increase capacity and reduce burden 5) PhysicianGP or ECP provides medical treatment and supervision when needed 6) Other healthcare professionals Involved when relating to the user’s goals
Collaboration
User-related meetings during the treatment phase	Weekly team meeting Daily dialogue between home trainer and therapists	Weekly team meeting Regular dialogue between home trainer and therapists	Biweekly team meeting Coaching on the job when needed

Abbreviations: RN, registered nurse; PT, physical therapist; OT, occupational therapist; NA, certified nurse assistant; HCA, unregulated healthcare assistant; GP, general practitioner; ECP, elder care physician; IC, informal care consultant; HCP, healthcare professional.

Table 4 Overview of Behavior Change Techniques Used by Reablement Teams

Group	Behavior change technique	Example
1. Goals and planning	Problem solving	Ask user to identify factors of influence and think of strategies to overcome barriers to perform desired behavior
	Action planning	Detailed planning of performance of the desired behavior (context, frequency, duration and intensity)
2. Feedback and monitoring	Feedback on behavior	Observing and providing feedback on performance of behavior
	Feedback on outcome(s) of behavior	Observing and providing feedback on the outcome of performance of the behavior
3. Social support	Social support (unspecified)	Arranging and/or providing practical or emotional help for performing the desired behavior
4. Shaping knowledge	Instruction on how to perform the behavior	Advise or agree on how to perform the desired behavior
5. Natural consequences	Information about health consequences	Providing information about health consequences of performing the desired behavior
	Information about emotional consequences	Providing information about emotional consequences of performing the desired behavior
7. Associations	Prompts/cues	Using environmental or social stimuli to prompt or cue the behavior
	Exposure	Systematically exposing to a feared activity to build confidence
	Associative learning	Teaching the user that certain behaviors or activities lead to positive outcomes or emotional responses
8. Repetition and substitution	Graded tasks	Setting easy-to-perform tasks, making them increasingly difficult, but achievable, until desired behavior is reached
10. Reward and threat	Incentive (self)	Using activities meaningful (end-goal) to the individual as a reward if they put effort in reaching sub goals to achieve the behavioral outcome
12. Antecedents	Restructuring the physical environment	Changing the physical environment in order to facilitate the desired behavior or create barriers to the old behavior (other than prompts/cues, rewards and punishments)
	Restructuring the social environment	Changing the social environment in order to facilitate the desired behavior or create barriers to the old behavior (other than prompts/cues, rewards and punishments)
13. Identity	Framing/reframing	Suggesting to adopt a perspective or new perspective on behavior (eg its purpose) to change cognitions or emotions about performing the behavior

Note: Groups are numbered in accordance with the groupings of the behavior change taxonomy by Michie et al.³⁶

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