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From presence to participationA resource to promote social inclusion within group homes
From presence to participation Page 1
Page 2 From presence to participation
From presence to participationA resource to promote social inclusion within group homes
From presence to participation Page 3
Department of Health
To receive this publication in an accessible format phone (03) 9096 8427, using the National Relay Service 13 36 77 if required, or email <[email protected]>
AcknowledgementsThis resource has been developed as part of a participatory community placement by occupational therapy students from Monash University. The development of this resource was made possible by the guidance of Brent Hayward, Office of Professional Practice within the Department of Human and Health Services, and the Disability Service Accommodation staff at North-East Melbourne area, North Division.
By Aleisha Gillespie and Eden Leung, July, 2016
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services, July, 2016
ISBN 978-0-7311-7001-2
Available at www.dhs.vic.gov.au/officeofprofessionalpractice
(1606032)
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Contents
Guide to developing support plans that promote social inclusion..........................................7Benefits of using the support plan template....................................................................................7
Social inclusion............................................................................................................................ 9
Identifying socially inclusive goals...........................................................................................10Template 1: Social life domains....................................................................................................11
Rating goals................................................................................................................................ 12Steps to identify goals with residents............................................................................................13
Example of rating importance.......................................................................................................13
Writing goals............................................................................................................................... 15Example of a SMART goal...........................................................................................................15
Plan for goals.............................................................................................................................. 16Example of steps.......................................................................................................................... 16
Template 2: Goal planning template – example...........................................................................18
Template 3: Progress notes..........................................................................................................19
Reviewing goals.........................................................................................................................20Template 4: Reviewing goals – example......................................................................................22
References.................................................................................................................................. 23
Appendices................................................................................................................................. 24Appendix 1. Social life domains and activities..............................................................................24
Appendix 2. Examples of SMART goals.......................................................................................29
Appendix 3. Example of goal – preparing a meal.........................................................................30
Appendix 4. Example of goal – volunteering.................................................................................31
Blank templates and rating scales............................................................................................32Template 1: Social life domains....................................................................................................32
Template 2: Goal planning template.............................................................................................33
Template 3: Progress notes..........................................................................................................34
Template 4: Reviewing goals........................................................................................................35
Rating scales................................................................................................................................ 36
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Guide to developing support plans that promote social inclusion
The aim of this guide is to help you develop a support plan that will promote social inclusion for residents.
The support plan is a legislative requirement of s. 54 of the Disability Act 2006.
What is a support plan?
‘A required document for service users of ongoing disability support. The document includes goals of service users, and strategies and support that have been planned out by disability service providers to achieve the goals.’(Victorian Government Department of Human services 2009)
The purpose of a support plan is to:
• record and identify the goals of the person with a disability• describe strategies and support from the disability service provider(s) intended to achieve the
person’s goals• include actions and resources required to achieve the goals; and• review and measure achievements and outcomes of goals
You can use goal setting to focus on the person’s needs and aspirations. This can help to promote social inclusion.
Support plans are person centred. The person with disability must guide the development of the plan.
The support plan must respond to the goals and aspirations of the person with a disability, and outline assistance from family and support networks. Personalise the format, content and language of the plan to meet the needs of the person with disability.
Take note
Support plans may also be called individualised program plans, person-centred plans, person-centred reviews, or lifestyle plans.
Benefits of using the support plan templateThis guideline helps you to develop high-quality support plans. It is supported with evidence from the literature. The templates provide you with strategies to develop socially inclusive goals, and review the outcomes of goals.
For staff, the guideline:• offers a structured format to guide the development of a support plan
• provides a standardised approach to recording and reviewing goals
• enhances communication among staff, residents and their families
• helps you to meet the legislative requirements of s. 54 of the Disability Act 2006.
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Take noteThe guideline focuses on social inclusion. It aims to help you develop socially inclusive goals, and broaden the scope of socially inclusive activities in the person’s daily life.
For people with disabilities, the guideline:• adopts a person-centred approach in the development and achievement of
personalised goals• will ensure plans are easy to understand
• facilitates involvement of family
• enhances social inclusion.
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Social inclusion
Social inclusion for people with a disability means:
• experiencing respect for their differences, their aspirations, and their rights to have control over their own lives
• having opportunities to contribute and participate in society in a meaningful way and feel valued• experiencing significant reciprocal relationships• having appropriate support, where necessary.
(Family and Community Development Committee 2014)
Take note
Use this definition when you develop the support plan, and identify goals.
A goal is an aim or target that a person strives for. It involves careful planning and setting timelines. Goals are important for making changes and achieving personal outcomes.
Steps involved in the achievement of socially inclusive goals include:• identifying socially inclusive goals
• rating goals
• writing goals
• planning goals
• reviewing goals and action plan for change.
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Identifying socially inclusive goals
To identify goals to promote social inclusion, see Template 1 for a list of social life domains derived from the International Classification of Functioning and Disability (ICF).
What is the ICF?
The ICF is a framework that describes the interaction between the person’s health, activity, environment and personal factors.(World Health Organization 2013)
Incorporate social inclusion in various activities within each of these domains so the person is a part of a community and has meaningful life roles. These activities should be used as a guide to lead the conversation with the person, and to identify the person’s interests.
Take note
Highlight or make note of the activities presented in Template 1 that the person is interested in. Use the ‘Importance rating scale’ on p. 9 to narrow down the number of activities.
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Template 1: Social life domains
Social life domain
The domains categorise different daily life activities that are associated with social inclusion.
Activities
Social inclusion does not only include leisure within the community, but also items as listed. Detailed explanation of each item is in Appendix 1.
Importance to person
Reason why it is important
Home life Buying things from the shops
Cooking food
Doing housework
Helping other people
Personal life with other people
Basic communications
Complex communications
Interacting with others in the community
Formal relationships
Casual relationships
Family relationships
Close relationships
Major life areas Learning simple skills
School education
Tertiary education
Paid job
Simple money handling
Independent money management
Community, social and public life
Community life
Leisure and play
Religion and beliefs
Human rights
Political life and citizen rights
Take notePresent this information in a way that the person will understand, for example, using pictures.
See Appendix 1 for advice on helping people understand the activities presented on the table.
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Rating goals
These rating scales help residents and family rate the importance of goals, and identify the current level of support the person needs to achieve the goal.
Allow the person to self-rate the importance of the goal. If they are unable to do this by themselves, involve a someone who knows the person well.
Importance
1Least important
2Not really important
3Important to me
4Really important to me
5Most important to me
Take note
You don’t have to use a picture of a star on rating scales. You can change the symbol to something that is meaningful to the person, for example something they find interesting.
When you have identified what is important to the person, you will need to understand the reason why, so you can write specific and relevant goals. Also, by understanding why the person wants to participate in the activity, you can arrange the activity in a way that is meaningful for the person.
Take noteWhen determining how many goals to set, consider the person’s ability, and staff capacity to monitor the progress and achievement of goals. The number of goals should be based on what is manageable and realistic, in order to maximise the person’s chances of success.
Once goals have been identified, it is important to know the level of support the person needs to achieve the goal. The person can use the rating scale below to determine this. If the person cannot use the rating scale, staff and family can help to identify the level of support.
Take noteKnowing the level of support the person needs will help to identify the resources needed to achieve the goal, and what is required from staff, family and others to assist in the achievement of the goal. This will be addressed in the resources and responsibility section of planning.
Level of support
1Maximum assistance
2With some assistance
3Minimum assistance
4Prompts only/ Supervision
5Independent
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The descriptions below define the different levels of support.
Level of support Description
Maximum assistance Person needs direct assistance from support staff for 80 per cent or more of the time when completing the task.
With some assistance Person needs direct assistance from support staff for about half the time when completing the task.
Minimum assistance Person needs direct assistance from support staff for less than 20 per cent of the time when completing the task.
Prompt only/supervision Person only needs verbal or visual prompts to complete the task, or supervision from support staff is only required for safety reasons.
Independent Person does not need any assistance or support from staff to complete the task.
Steps to identify goals with residents• List the social life domain activities, and work with the person and others to identify the
activities they are interested in. • Rate the identified activities according to the importance to the person, using the rating
scale provided. • Through discussion, identify why these goals are important, as this will help in writing
goals that are meaningful for the person.• Highlight or make note of the activities the person rated as most important to them.
Activities that scored the highest on the importance rating scale will be used to form the goals.
• Once goals have been identified, use the rating scale to identify the level of support the person needs to achieve the goal.
In the following table, cooking meals, informal relationships and community life scored the highest ranking in importance. These will form the goals.
Activities Importance to client
Reason why it is important
Buying goods and services
3 I want to help in choosing groceries. I would like to help more.
Cooking meals 5 I want to learn how to make breakfast.
Informal relationships 5 I want to see my friends more often.
Community life 5 I want to make new friends and go out with them.
Leisure and play 4 I like basketball and want to play in a team.
Example of rating importance
Take note
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Keep in mind that goals need to be person centred. The person and their family should direct the development of goals. Staff can guide and facilitate if needed, but goals should match the person’s interest and aspirations.
The person can rank themselves (with or without assistance) using the ratings scales.
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Writing goals
The best way to write goals is to use SMART goals. This will help you develop goals that are detailed, and can be measured. SMART stands for goals that are:
Specific: provide a detailed description of the goal. The more detailed the goal, the more likely it will be achieved. Think about who, what, where and when.Measurable: describe how progress will be made. This will help you determine whether the goal has been achieved. Measurement can be based on numbers, for example how many sessions attended, or descriptive, for example how much the person enjoyed the activity.Achievable/attainable: the person must be able to accomplish the goal, considering their abilities and the resources and support available. Consider the barriers and challenges the person faces, and how these can be overcome.Relevant/realistic: goals need to be realistic, based on the person’s capabilities, availability of resources, and schedule. Goals must have meaning for the person and be relevant to their desires.Time: include a deadline for achieving the goal.*Note: This description of SMART goals is from two sources referenced in the reference list.
Example of a SMART goalTake note
When writing a goal, it is important to note if the person wants to increase their skills or participation in an activity, or if they want to maintain their current level. This will be important when it comes to reviewing the outcome of the goals.
Dan will attend a movie session at the local cinemas (specific) accompanied by a friend of his choice (relevant/realistic), with minimal assistance as specified in responsibilities and resources (achievable/attainable) within four months (time/measurable).
This is an example of a socially inclusive goal. For more examples refer to Appendix 2.
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Plan for goals
In order to develop a solid plan for goals, staff need to consider the following: steps and strategies, responsibilities and resources, timeline, date action occurred, progress notes, and review date. These components will be described below in greater detail.
Steps and strategiesTo help measure and monitor the progress, break goals down into smaller steps with accompanying strategies. Steps assist planning and monitoring the progression of the goal. Strategies look at how the goal will be achieved, by breaking down the steps into specific tasks. See Template 2 for an example.
Take noteTo determine what the steps are, ask, ‘What activities does the goal include?’
To determine what the strategies are, ask, ‘How will these steps be achieved?’
Example of stepsSee Template 2 for accompanying strategies for the steps provided.
Dan will choose a movie he would like to watch Dan will choose a friend or family member he would like to go to the cinema with.Dan will record his plans in his diaryTransport will be organised for Dan to attend the movies.Dan will buy tickets at the counter with his own money.
Breaking the SMART goal into individual steps and strategies will:
• assist in measuring the outcome for the person• help in monitoring the progression towards the goal• assist in achieving the goal.
Take noteSee ‘Date action occurred and progress notes’ for further guidance in monitoring goals.
Responsibilities and resourcesThis section lists out the resources required to successfully achieve the goal. Resources include things like transport, access to computers, or money. This section also addresses the role that staff, family members and other people play in assisting the person to achieve their goals. For example, it may state the level of support required from the support worker, or resources that other people can use to help the person successfully achieve the goal, such as using a communication tool.
TimelineSet a time limit for when each step is to be achieved by. This will help monitor progress towards achieving the goal. Time limits need to be realistic and achievable, according to the capacity of the
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person and supporting staff. A time limit for goals can be anywhere from a week to a whole year, depending on the individual circumstances.
Date action occurred and progress notesRecord the date that action occurred in order to monitor and review progress notes. This will help you reflect on the person’s strengths and support needs. You can use these notes to inform an action plan once the outcome of a goal has been achieved. See Template 3 for a progress notes template. You don’t have to use this template if you already have a recording system in place.
Review dateRecord the date for review to prompt a discussion of the outcome. Include when and where the meeting will be held, and who will be present. It is best to set the date near the completion of the goal to allow for immediate reflection and improvement.
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Template 2: Goal planning template – example
Goal
Dan will be to attend a movie session at the local cinemas accompanied by a friend of his choice, with minimal assistance as specified in responsibilities and resources, within four months time.
Review date
8 May 2016
Steps Strategies Responsibility and resources Timeline
1. Dan will choose a movie he would like to watch.
Dan will find out what movies are playing at his local cinema by looking at cinema’s website or newspaper. Dan will pick a movie by watching trailers online.
Staff will provide Dan access to computer or newspaper. Staff will verbally assist Dan in using the computer. Hands-on assistance will be provided if needed.
First week of beginning the goal
2. Dan will choose a friend/family member he would like to go to the cinema with.
Dan will call his friend or family member to check when they are available to watch a movie.
Staff will remind Dan to refer back to the telephone book for telephone numbers.
Second week
3. Dan will record his plans in his diary
Dan will write who, what, when and where the movie is in his diary.
Staff will remind Dan what to record in his diary if necessary. Staff will ask Dan to read what he has written in his diary to check the details are correct.
Second week
4. Transport will be organised for Dan to attend the movies.
Dan will choose whether to use the group home’s transport, public transport or friend’s vehicle to go to the cinema.
Staff will organise mode of transport and necessary resources required (such as myki card).
Third week
5. Dan will buy tickets at the counter with his money.
Dan will pay for the tickets with the correct amount of money.
Staff will help Dan calculate the amount of money he needs, and make sure he has enough in his wallet.
Fourth week
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Template 3: Progress notesDate Step Progress
In this section write: what happened, and the person’s strengths and support needs when completing the step.
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Reviewing goals
The template on the following page can be used to help review goals. It consists of four sections: what worked well, what didn’t work well, what needs to be changed, and a plan of action.
What worked well?Discuss the positive things that occurred while achieving the goal. This may include skills the person used, strategies that staff, family and others used which were effective, and events that led to the success of the goal.
What didn’t work well?Discuss the difficulties and obstacles. This may include further development of certain skills, environmental factors, lack of resources, and use of ineffective strategies.
What needs to change?Discuss the challenges and difficulties faced, and identify changes needed in order to make the goal achievable (if goal has not been achieved by review date).
Plan for actionIn this section, note the conclusion you come to with the person about the outcome of the goal. Together, decide whether the person has achieved more or less than expected, or maintained the same level.
Take note
Achieving less than expected is not necessarily a bad outcome. It may simply mean that different strategies or approaches are needed. Also, maintaining the same level of skill or participation may be positive if this was identified to be outcome of the goal.
From this, develop a plan of action to address the issues and challenges. This may include enhancing the person’s skills, modifying the environment, modifying strategies used by staff, family and others, and so on.
Take note
Record how and when the support is reviewed, and who is involved, in the support plan. This is important when several disability providers are involved.
To identify the person’s overall satisfaction with the outcomes, you can use the five-point satisfaction scale below.
Some questions that you may ask to understand the person’s satisfaction:
• How happy are you with the support you received?• How happy are you with what you achieved through the goal?
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Satisfaction
1Not happy at all
2Not really happy
3Somewhat happy
4Happy
5Really happy
After determining the level of the person’s satisfaction with the outcome and process of the goal, find out if they would like to continue with this goal, or move on to another one. Use the diagram below as a visual cue.
GO – continue working on the goalSTOP – to finish working on the goal
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Template 4: Reviewing goals – exampleLevel of satisfaction:
Support:
Achievement:
Goal: 1
A picture of a tick
What worked well?Dan chose a movie he wanted to watch by viewing trailers online. He enjoyed watching the trailers, and kept asking staff if he could watch more. He even invited one of his friends to help him choose a movie. Dan invited this friend to the movies with him.
A picture of a cross
What did not work well?Dan needed the most help when using the computer because he had difficulty navigating the pages. He had trouble using money. He gave money to the cashier, but did not wait for his change. Staff had to verbally prompt Dan to give the cashier the money, and to collect the change.
A picture of to and from arrows
What needs to change?Goal may not be appropriate for Dan at this stage as he requires the further development of certain skills. Therefore the goal needs to be revised to make it achievable. Staff to teach him skills in using the computer, and basic money handling.
The three choices below allow the person, staff and family to come to a conclusion about the outcome of the goal.
Plan for actionTick or mark with an X the appropriate answer
Achieving greater than expected
Maintaining current skills/level of participation
Achieved less than expected
Goal needs to be reviewed and changed before (insert date).
Strategies to achieve goal need to be reviewed to give Dan the necessary support to achieve the goal. Further steps are required, when completing this goal again with Dan.
Dan may benefit from assistance that teaches him how to use the computer, and how to use money → these can be made into separate goals.
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References
Bovend’Eerdt TJ, Botell RE and Wade DT 2009, ‘Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide’, Clinical rehabilitation, vol. 23, no. 4, pp. 352–361, doi: 10.1177/0269215508101741
Family and Community Development Committee 2014, Inquiry into social inclusion and victorians with disability, Family and Community Development Committee, Melbourne, pp. 6–12.
Parliament of Victoria 2006, Disability Act 2006 (no. 23), retrieved from <http://www.austlii.edu.au/au/legis/vic/consol_act/da2006121/>.
Takahashi T 2005, ICF illustration library English version, ICF illustration library, retrieved 10 March 2016 from <http://www.icfillustration.com/icfil_eng/>.
Turner-Stokes L, Nyein K, Turner-Stokes T and Gatehouse C 1999, ‘The UK FIM+FAM: Development and evaluation’, Clinical Rehabilitation, vol. 13, no. 4, pp. 277–87, <http://dx.doi.org/10.1191/02692159967689679>.
Victorian Government Department of Health and Human Services 2009, Disability services planning policy: Disability Services Division 2009, State Government of Victoria, Melbourne, retrieved from <http://www.dhs.vic.gov.au/about-the-department/documents-and-resources/policies,-guidelines-and-legislation/disability-services-planning-policy-2009>
Werle Lee K P 2010, ‘Planning for success: setting SMART goals for study’. British Journal of Midwifery, vol. 18, no. 11, pp. 744–746, doi: 10.12968/bjom.2010.18.11.79568
World Health Organization 2002, Towards a common language for functioning, disability and health, World Health Organization, Geneva, retrieved from <http://www.who.int/classifications/icf/en/>.
World Health Organization 2013, How to use the ICF: a practical manual for using the International Classification of Functioning, Disability and Health (ICF), exposure draft for comment, World Health Organization, Geneva, retrieved from <http://www.who.int/classifications/drafticfpracticalmanual2.pdf?ua=1>
World Health Organization 2015, ICF browser, World Health Organization, retrieved 10 March 2016, from <http://apps.who.int/classifications/icfbrowser/>
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Appendices
Appendix 1. Social life domains and activities
Social life domain: Home life
Activity
Buying things from the shops
Description
Getting all goods and services required for daily living
Examples:
Shopping and gathering food, drink and clothing
Buying cookware and domestic tools
Activity
Cooking food
Description
Cooking meals for oneself and others
Examples:
Cooking meals
Choosing food and drink
Serving the food
Making a menu
Getting the ingredients together
Activity
Doing housework (cleaning house, washing dishes, laundry, ironing)
Description
Taking care of the house by cleaning the house
Examples:
Washing clothes
Throwing away garbage
Sweeping
Tidying rooms
Ironing clothes
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Activity
Helping other people
DescriptionHelping members of the house and others, and caring for housemates and others.Example:
Helping others with self-care, moving around, communication
Social life domain: Personal life with other people
ActivitiesBasic communications
DescriptionsInteracting with people in an appropriate mannerExamples:• Showing respect and warmth in relationships
• Responding to social cues in relationships
• Using proper physical contact in relationships
ActivitiesComplex communications
DescriptionsManaging interactions with other people, in an appropriate manner Examples:• Starting and ending relationships
• Controlling behaviours within conversations
• Interacting according to social rules
• Maintaining social space
ActivitiesInteracting with others in the community
DescriptionsBrief contact with strangers for particular purposesExamples:• Asking for directions
• Buying goods
• Saying ‘Thank you’
ActivitiesFormal relationships
DescriptionsMaking specific relationships in formal settings, such as with employers, professionals or service providers
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Examples: • Talking with boss, with clients and with colleagues
• Talking with doctors
ActivitiesCasual relationships
DescriptionsStarting relationships with others, such as casual relationships with people living in the same community, or with co-workers, students, playmates or people with similar backgroundsExamples: Talking to friends, neighbours and housemates
Activities Family relationships
DescriptionsKeeping family connections, such as family members, relatives, guardians Examples: • Talking to parents
• Going out with brothers and sisters
Activities Close relationships
DescriptionsMaking close or romantic relationships between persons, such as spouses, lovers or sexual partnersExamples: Romantic, spousal and sexual relationships
Social life domain: Major life areas
ActivitiesLearning simple skills
DescriptionsLearning at home or in some other non-school settingExamples:• Learning crafts and other skills from parents or family members
• Learning cooking and gardening at home
ActivitiesSchool education
DescriptionsGoing to schoolExamples:• Studying the course materials in a primary or secondary education program
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• Attending school regularly
• Working with other students
• Listening to teachers
• Doing coursework and projects
ActivitiesTertiary education
DescriptionsGoing to universities, colleges and professional schools Example:• Completing a university course of study
ActivitiesPaid job
DescriptionsDoing different jobs for paymentExamples: • Finding and getting a job
• Doing the required tasks of the job
• Going to work on time as required
• Teaching other workers or being taught
• Doing required tasks alone or in groups
• Self employment or part-time/full-time job
ActivitiesSimple money handling
DescriptionsInvolved in any simple use of money Examples:• Using money to buy goods or services
• Saving money
ActivitiesIndependent money management
DescriptionsHaving full control in money from private or public sources Example: • Plan for the use of money for now and future
Social life domain: Community social and public life
ActivitiesCommunity life
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DescriptionsInvolved in social life within communityExamples: • Joining informal and formal clubs
• Joining ceremonies
• Volunteering
• Helping in charity
ActivitiesLeisure and play
DescriptionsEngaging in play or leisure activityExamples: • Playing sports,
• Going to art galleries and museums
• Going to cinemas or theatres
• Sightseeing and travelling
ActivitiesReligion and beliefs
DescriptionsInvolved in religious activities and organisationsExamples: • Attending a church or mosque or place of worship
• Praying
• Meditation
ActivitiesHuman rights
DescriptionsEnjoying all nationally and internationally recognised rights that are given to peopleExamples:• To choose for yourself
• To have control over your future
ActivitiesPolitical life and citizen rights
DescriptionsTaking part in the social, political and governmental life as a member of the communityExamples:• Voting
• Forming political associations
• Exercising legal rights
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• Being protected against discrimination
*Note: Images and descriptions were taken and adapted from ICF illustration library and can only be used for non-commercial purpose. You can adapt the images to help with communication with residents. You can also use other communication aids to help residents to understand the social inclusion activities.
Retrieved from ICF browser: <http://apps.who.int/classifications/icfbrowser/>
ICF illustration library: <http://www.icfillustration.com/icfil_eng/>
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Appendix 2. Examples of SMART goalsHomes life goals
Buying things from shops
Goal: Tania will be able to help locate and purchase the groceries needed for a weekly dinner at her local grocer during a single shopping trip (specific), with assistance from staff referring to responsibilities and resources (achievable/realistic) once a fortnight (measurable) within six months’ time (time).
Personal life goals with other people
Casual relationships Goal: With skills learnt from support workers, Henry will be able to maintain weekly conversation (specific) for approximately five minutes (measurable) with another resident or support worker (relevant), with minimal assistance referring to responsibilities and resources (achievable), within eight months’ time (time).
Family relationships Goal: Michael will go on an outing, of an activity of his choice (specific/relevant) with his family, on a monthly basis (measurable), with assistance from both staff and family members referring to responsibilities and resources (achievable) within seven months’ times (time).
Major life areas goals
Simple money handling
Goal: Stephanie, given money handling education from staff (specific), will be able to purchase her lunch from the café once a week (measurable) at a weekly outing, with assistance from staff referring to responsibilities and resources (achievable), by nine months’ time (time).
Community, social and public life goals
Leisure and play Goal: Ryan, given assistance from staff referring to responsibilities and resources (achievable), will join a sporting team within the local area (specific) where he will attend once a week (measurable) to make new friends and get exercise (relevant) by six months (time).
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Appendix 3. Example of goal – preparing a mealGoal: Dan will be able to cook dinner in the group home and invite housemates of his choice, with minimal assistance from staff, within two months’ time.
Steps Strategies Responsibilities and resources
Dan will choose what to cook for the dinner.
Dan will pick his favourite recipe from the cookbook or cooking websites.
Staff will provide Dan a computer to search for recipe. Staff will borrow a cookbook from the public library for Dan. Staff will print or photocopy the recipe for Dan.
Dan will buy the ingredients required for the recipe.
Dan will make sure that he has his shopping list with him when he is going to get the groceries.
Staff will write the shopping list and give it to Dan to keep safe. Staff will go to the local grocers to help Dan to buy the ingredients needed in the supermarket. Staff will encourage Dan to pick ingredients he needs at the local grocers.
Dan will cook the dinner
Dan will bring the recipe to the kitchen at dinner time. Dan will follow the steps on the recipe and select the correct utensil for staff to use. Dan will handover the ingredients to staff when it is needed, and with assistance will stir the ingredients in the pot,
Staff will verbally prompt Dan to pass necessary ingredients utensils according to the recipe. Staff will accompany Dan during cooking to ensure safety.
Dan will invite housemates to dinner if he wanted.
Dan will politely ask his housemates to dinner with use of communication aid. Dan will collect cutlery, and will help to set up table.
Staff will assist in communication when necessary, and help Dan to set up the table.
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Appendix 4. Example of goal – volunteeringGoal: Megan will get a volunteer position which involves gardening within her local area, with minimal assistance, where she will attend once a week to assist in the upkeep of the garden and make new friends, within seven months.
Steps Strategies Responsibilities and resources
Megan will increase skills in gardening.
Megan will develop a small garden with four plants that she has bought from the store. Gardening tools will also be bought. Megan will develop a list of what she has to do to care for her plants, which she will refer to everyday.
Staff will accompany Megan to the store to buy plants and gardening tools.Staff will research if there is a free DIY workshop to teach Megan gardening skills.
Megan will develop a resume.
Megan will develop a resume using a template on Microsoft Word.
Mum will provide Megan with the computer, and will type up resume with direction from Megan. Mum will proof read resume and make changes appropriately and print.
Megan will find volunteer opportunities that is focused around gardening.
Megan will look for gardening volunteer opportunities within her local area by looking online. Megan will choose four volunteer positions that she likes.
Staff will provide Megan with verbal assistance to use and navigate the computer. Staff will allocate time twice a week for two weeks to help Megan find volunteer opportunities.
Megan will express interest in the four volunteer positions she likes.
Megan will contact volunteer organisations by email or phone call to express interest in the positions. Megan will write down what she will say to the volunteer agency.
Staff will help Megan plan what she will say on the phone and what she will send by email. Staff will type up email for Megan.
Megan will attend interviews for volunteer positions.
Megan will practice interviewing skills with staff and family on different occasions, twice a week.
Staff and family will organise time to practice interview skills with Megan.
Megan will volunteer once a week.
Megan will attend the volunteer position once a week, by public transport (initially with assistance). Once Megan feels confident in using public transport she will attend independently.
Megan’s mum will buy a myki card. Staff will teach Megan how to use public transport. Staff may find if there are any programs to learn how to use public transport.
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Blank templates and rating scales
Template 1: Social life domainsSocial life domain
Activities Importance to person
Reason why it is important
Home life Buying things from the shops
Cooking food
Doing housework
Helping other people
Personal life with other people
Basic communications
Complex communications
Interacting with others in the community
Formal relationships
Casual relationships
Family relationships
Close relationships
Major life areas Learning simple skills
School education
Tertiary education
Paid job
Simple money handling
Independent money management
Community, social and public life
Community life
Leisure and play
Religion and beliefs
Human rights
Political life and citizen rights
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Template 2: Goal planning template Goal
Review date
Steps Strategies Responsibility and resources Timeline
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Template 3: Progress notesDate Step Progress
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Template 4: Reviewing goalsLevel of satisfaction:
Support:
Achievement:
Goal: 1
What worked well?
What did not work well?
What needs to change?
Plan for actionTick or mark with an X the appropriate answer
Achieving greater than expected
Maintaining current skills/level of participation
Achieved less than expected
Goal needs to be reviewed and changed before (insert date).
Other notes:
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Rating scales
Importance
1Least important
2Not really important
3Important to me
4Really important to me
5Most important to me
Level of support
1Maximum assistance
2With some assistance
3Minimum assistance
4Prompts only/ Supervision
5Independent
Satisfaction
1Not happy at all
2Not really happy
3Somewhat happy
4Happy
5Really happy
Continue or stop goalGO – continue working on the goalSTOP – to finish working on the goal
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Page 40 Document title