Rehabilitation and goal setting for older patients
Choosing who suits rehabilitation, the ICF framework, writing SMART goals, goal attainment scaling with a worked hip fracture example, FIM, Barthel and AN-SNAP, Australian rehabilitation and GEM settings, and when goals should turn palliative.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Rehabilitation aims to restore function and participation in what matters to the person, not to normalise test results. Goals are the steering wheel.
- Frame problems with the WHO ICF: impairment (weak quadriceps), activity (can't climb stairs), participation (can't get to church).
- Write goals with the person and family, make them SMART, and measure them. Goal attainment scaling (GAS) turns personal goals into a number.
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Sources
- AFRM Standards for the provision of inpatient adult rehabilitation medicine services in public and private hospitalsAU/NZAustralasian Faculty of Rehabilitation Medicine, RACP, 2019
- Australasian Rehabilitation Outcomes Centre (AROC)AU/NZUniversity of Wollongong
- International Classification of Functioning, Disability and Health (ICF)World Health Organization, 2001
- Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation (Levack WM et al. Cochrane Database Syst Rev 2015;7:CD009727)Cochrane, 2015
- Goal attainment scaling (GAS) in rehabilitation: a practical guide (Turner-Stokes L. Clin Rehabil 2009;23:362-70)Clinical Rehabilitation, 2009
- Transition Care ProgrammeAU/NZAustralian Government Department of Health, Disability and Ageing
- Support at Home programAU/NZAustralian Government Department of Health, Disability and Ageing, 2025
- Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery (Smith TO et al. Cochrane Database Syst Rev 2020;2:CD010569)Cochrane, 2020
- Interventions for improving mobility after hip fracture surgery in adults (Fairhall NJ et al. Cochrane Database Syst Rev 2022;9:CD001704)Cochrane, 2022
- Last updated
- 14 November 2026
What changed
- 14 November 2026 Personal emails, About story and Australian-style copy