< All Topics

7. Needs, Outcomes, and Goals

The Needs, Outcomes, and Goals are made based on the participant’s services.

There must be a Need/Outcome/Goal for each service (except Service Coordination*) until you run out of available Needs/Outcomes/Goals. 


Details why the participant Needs the service or what they need help with specifically requiring the service. 


These are meant as a guide to the format of the Needs.

Always ask the participant “Why do you need this service?”


Why does the participant need a caregiver/what is the caregiver going to help them with?

  • Ms. Amcord needs assistance with Meal Prep, Housework, Shopping, Transportation, Bathing, Personal Hygiene, Dressing, and Locomotion due to arthritis pain. (*Can also choose one specific IADL/ADL*)
  • Ms. Amcord needs to improve mobility
  • Ms. Amcord is unable to bathe due to pain and needs to improve personal hygiene
  • Ms. Amcord needs to decrease hospitalizations related to falls that take place while completing bathing, dressing, and ambulation


Why does the participant need a PERS unit/what will the device do for them?

  • Ms. Amcord needs constant access to Emergency Medical Services (EMS)
  • Ms. Amcord is unable to dial her phone due to arthritis and needs to be able to access EMS as needed
  • Ms. Amcord needs to be able to attain assistance from EMS should a fall/injury take place


Why does the participant need home delivered meals/what will the meals provide them?

  • Ms. Amcord needs to better manage her health through diet and nutrition
  • Ms. Amcord needs to better manage her diet and food portion intake
  • Ms. Amcord needs to have access to 2 meals per day to maintain her physical well being


Why does the participant need to attend ADC?

  • Ms. Amcord needs to improve her socialization skills
  • Ms. Amcord is diagnosed with dementia and needs constant supervision/assistance with ADL/IADL’s throughout each day
  • Ms. Amcord needs to improve her depression/anxiety

Status of Need: Met, Unmet, Partially Met

Met: This indicates that the Need is already being addressed fully, through either informal, formal, or a combination of both types of assistance

Partially Met: This indicates that the Need is only partially met at the time of assistance (ie. Participant may be forgetting to take their medications for diabetes 50% of the time and is therefore still hospitalized related to high blood sugar levels)

Unmet: This indicates that the Need is unaddressed by either formal or informal assistance at this time. (ie. Participant has arthritis and can not dial the phone and lives alone, so does not have access to Emergency Medical Services)

Blank Space


Details the Outcome on the participant’s life/health/well-being if the Need is satisfied. 

Always ask the participant, “What are you hoping to achieve by satisfying the previously stated need?”



If the need was “Ms. Amcord needs to improve personal hygiene” then how will improving the daily hygiene affect the participant’s life/health?

  • Due to improved hygiene Ms. Amcord will be able to go to church on Sundays and to her local senior center on Tuesdays and Thursdays each week
  • Ms. Amcord will improve her personal hygiene and will be able to go to activities in the community, such as bingo and church.


If the need was “constant access to EMS” how will having this constant access help/benefit the participant?

  • Ms. Amcord will feel more confident ambulating around her house when no one is around if she is able to quickly contact EMS in case of a fall or other emergency
  • Ms. Amcord will receive prompt care/treatment of injuries, reducing the long-term impact with quick access to contact EMS in the event of an emergency. 


If the need was “manage her health through diet and nutrition” then how will improving diet and nutrition affect the participant’s life/health?

  • Ms. Amcord will have diabetic appropriate/heart healthy meals to help reduce hospitalizations
  • Ms. Amcord will lose weight with pre-made, pre-portioned, nutritious meals.
  • Ms. Amcord will have more energy throughout the day with an improved diet.


If the need was “to improve socialization” then how will increased socialization help the participant in life?

  • Ms. Amcord will reduce her depression through more socialization with her community
  • Ms. Amcord will have a more positive outlook in life by regularly spending time out of her home and interacting with others.  

Blank Space


Details the participant’s Goal in having, receiving, or utilizing the service to satisfy the Need for it and obtain the desired Outcome.

All Goals have to be SMART, meaning it must include statements pertaining to each letter of the SMART acronym

S – Specific

The goal must be clearly stated and detailed using person-centered statements.

Ask yourself and/or the ptp: “Why?” or “How?” – such as “why this goal” – “why do you need this?” – “How will this goal help the participant” – “How is this goal different/specific to this participant”

Not specific goalSpecific goal
I would like to stay in my home.”“John would like to stay in his home where he is most comfortable and happy
This statement does not mention how staying in his home is specific to him vs. anyone else.This statement is specific to John and his preferences.

Hint – address the participant’s barrier they are trying to overcome with this service.

  • Ex. “Ms. Amcord’s goal is to receive hands on assistance with tasks due to limited mobility caused by arthritis
M – Measurable

Definable/Quantifiable supports needed to achieve the goal are identified

Not measurable goalMeasurable goal
“Jane’s goal is to improve her mental health by getting a good night’s sleep every night”“Jane’s goal is to improve her mental health by sleeping at least 4-6 hours per night.”
This is not measurable; there is no way to measure/quantify a ‘good night’s sleep’.This is measurable. We can identify the amount of sleep she gets each night.
A – Attainable 

The goal needs to be realistic/tangible. Therefore there is a better chance of it being regularly successful

Not attainable goalAttainable goal
“I want to be smoke free.”“Sam would like to smoke less than 10 cigarettes per day.”
This is not attainable, because smoking a single cigarette would mean failure in attaining the goal, which can be demoralizingThis is attainable. There is more leeway so that Sam can either smoke 0 cigarettes (and be smoke free!) or if he smokes a few on a bad day, it won’t derail his progress.
R – Realistic/Relevant 

The goal must relate to the needs/overall goals of the participant and to what the service can provide.

Ask the participant if they feel the goal can realistically be accomplished. Then ask yourself if the goal is relevant to what the service can provide

Not realistic/relevant goalRealistic/Relevant goal
“I want to improve mobility by receiving HHA assistance.”“Stephanie’s goal is to receive hands on assistance from her HHA when walking to maintain and improve mobility.”
This is not realistic/relevant. The participant may not be at a stage of improving mobility and it is not relevant to an HHA’s responsibilities. This is more realistic/relevant to the participant and the service. The goal was shifted to receiving assistance, rather than improving mobility. Therefore it is realistic in terms of being accomplished and relevant to what the HHA can do.
T – Timebound 

There is a timeframe for completing or reassessing the goal. You do not want to leave goals open-ended and continuing on forever (even if that’s really what we want/need).

Ask the participant if this is a long term, or short term goal, when they would like it to be completed by, or when we should reassess the goal to either continue it, or change it.

Not timebound goalTimebound goal
“Bill’s goal is to remember to take his blood pressure medication every morning.”“Bill’s goal is to remember to take his blood pressure medication every morning for the next 12 months.”
This is not timebound as there is no ending timeframe. It is just going on forever. This is timebound. Even if the participant believes they will need to take the medication forever, we want to set a timeframe for reassessing the goal in case his health or situation changes!

The first sentence of a Goal is the defined SMART goal. The following sentences should better describe details of how the goal will be completed to meet the desired outcome.


Veronica will maintain proper nutrition and a healthy diet (S) by receiving 7 low sodium meals every week (M) for the next 6 months (T, A, &R). Veronica will have one HDM for lunch every day of the week when her HHA or informal support is not with her to prepare fresh meals. Veronica requested low sodium meals to reduce the risk of potential health complications due to hypertensive heart diseases.

Dan will use his PERS so that he may go for a 30 minute walk (S) every day, Monday-Sunday, (M) with or without his HHA for the next 3 months (T) to improve his mobility and be able to access EMS if needed (A&R). Dan will go for walks with his HHA Monday-Friday and will go out independently on Saturday and Sunday. Dan will wear his PERS unit when he goes for walks without his HHA to have quick access to EMS in case of an emergency. 

Aaron’s HHA will assist with showering, grooming, and dressing (S) 7 days per week (M) for the next year (T) in order to maintain healthy personal hygiene (A&R). The HHA will assist the participant with transfers in and out of the shower as well as provide hands on assistance with washing hair, legs and back every morning (Monday-Sunday). HHA will assist Aaron with dressing twice a day, 7 days a week (once in the morning and once in the evening). HHA will brush Aaron’s hair daily and assist with prepping his toothbrush and reminding Aaron to brush every morning and evening. 

John will have zero (M) instances of bed sores(S) in the next year(T), by having assistance with bathing, dressing, grooming, transfers, repositioning, and toileting Monday-Sunday each week(A&R).  John will have assistance from Caregiver with these tasks, Monday through Friday from 9a-3pm and informally from his daughter/Jane during the evenings as well as on Saturday and Sunday each week.

Beth will decrease hospitalizations related to high glucose levels (S) to less than 1 time per 6 months(M) for the next year (T, A, &R).  Beth will have access to least 2 diabetic appropriate meals, per day, 7 days per week for the next year to help decrease hospitalizations.  Beth will attend all of her medical appointments and take medications daily.

  • Agree/Disagree- If both the participant and the Service Coordinator agree on the goal then “Agree” is selected.  If either the SC or the participant do not agree to some aspect of the goal then “disagree” should be selected.  
  • Start Date– Goals should be built upon from one PCSP to the next.  If the participant has just chosen the goal to work on for the first time at the visit then “Start Date” would be the date of the visit.  If the participant has been working on this goal from prior PCSP’s then the true start date of the goal should be obtained from the prior PCSP.
  • End Date– The end date must always be current and should be based off of the
    “Timebound” portion of the actual goal.  If at the visit/assessment the participant states that they want to work on the goal for 6 months then the end date should be six months from the date of the visit.  
  • Barriers – Something that prevents the participant from achieving their goals.  If a participant has no informal supports this needs to be documented in the barriers.
    • Ex. Veronica is unable to cook without assistance due to pain in her back, preventing her from standing for longer than 5 minutes. 
    • Ex. Dan forgets to charge and wear his PERS until when his HHA is not around. 
    • Ex. John has no informal support to be able to assist him with bathing, dressing, and grooming.
    • Ex. Beth is low income and is unable to purchase diabetic appropriate foods to meet her medical needs.
  • Intervention – What can/will be done to overcome the barrier and proceed with achieving the goal.  If a participant has informal support they need to be listed in the interventions with the specifics of what they will be assisting with.
    • Ex. Veronica’s HHA will assist with meal prep in the morning and afternoon and will have HDM ready for Veronica to heat up for dinner when she is not around.
    • Ex. Dan’s HHA will ensure the PERS unit is charging while they are there to supervise Dan’s walks, and will remind him to wear the PERS unit when they leave for the weekend. 
    • Ex. John’s daughter/Jane will assist him with dressing and grooming before bed each night, Monday-Sunday. 
    • Ex. Beth’s son/David will do grocery shopping for heart healthy foods each Sunday 
Previous 6. Service Plan
Next 8. LTSS/SRT Guide
Table of Contents