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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. 

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


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


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.

Get S.M.A.R.T details from the participant/responsible party! Do NOT try to complete this without participant input.

1. Start with a basic goal for the service such as:

**Hint: this can or likely will be similar to the NEED of the service**

  • Receive assistance with ADLs and IADLs
  • Go outside more
  • have assistance in case of falls or emergencies
  • improve socialization
  • improve diet/nutrition
  • continue living independently

2. Go through each letter of the SMART acronym to add onto the goal

S – Specific

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

Ask the ptp: “Why?” or “How?” – such as “why do you want to achieve this goal” – “how does this goal relate to your needs?” – “How is this goal different/specific to this participant”

Goal example: To receive assistance with bathing and personal hygiene

Specific example: you can ask the participant “why do you need help with bathing and hygiene?” and their answer could be something like:

  • I need help because I have a lot of pain in my knees from my arthritis
  • I need help getting in and out of the tub because I can’t step over the tub
  • I need help staying clean because I keep getting infections on open wounds on my legs
M – Measurable

The goal must have Definable/Quantifiable supports for when/how often the goal will be done

Ask the ptp: How often/when do you need to do the goal?

Goal Example: To improve socialization by going to the community/senior center more often

Measurable example: ask the participant how often they’d like to go to the community center and their answer could be something like:

  • I want to go to bingo every Tuesday night
  • I want to go out twice a week
A – Attainable 

The goal needs to be realistic for them to complete. Make sure it is realistic to the participant’s capabilities and that you aren’t aiming too high or too low.

After making the goal ask yourself if the goal is something the participant is physically and mentally capable of completing AND that the measure is not too out there. For example, an 87 y/o is probably not physically capable of “improving” their mobility.

Goal example: to lose 50 lbs in the next year by receiving HDM

Attainable check example: Confirm the participant’s current weight, if this is all that’s needed to lose the weight, and if a physician agreed this would be able/safe to be done. After all:

  • A participant that only weighs 120 lbs probably won’t be able to lose that much weight
  • Exercise may also be needed for a participant to lose weight
  • A physician may feel that HDM won’t be able to provide enough nutrition to a participant.
R – Relevant 

The goal must be relevant to what the service actually can provide.

Ask yourself if this is something the service is meant for. Example:

  • PAS providers/HHAs provide assistance with ADLs and IADLs. They aren’t responsible for improving mobility
  • PERS units provide access to calling EMS. They can’t prevent falls or help a participant walk
  • HDM provides pre-made meals. It is not responsible for helping the participant lose weight.
  • Transportation gets ptps to and from appointments. It does not improve socialization
T – Timebound 

There must be a timeframe for completing or reassessing the goal. You do not want to leave goals open-ended and continuing on forever.

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.

Goal example: to have assistance if a fall occurs when they are home alone.

Timebound example: ask the participant how long they intend on having the PERS unit

  • for the next 6 months
  • for the next year

3. Pull all the information together to make the SMART goal


PAS example: Goal is to have help with bathing, dressing, and grooming

S – Specific – Ms. Smith needs helps because she was diagnosed with arthritis and states the pain stops her from doing those tasks herself

M – Measurable – once a day, 7 days a week

A – Attainable – with assistance from an HHA the participant should be able to meet this goal

R – Relevant – Ms. Smith will receive hands on assistance from her HHA, which is relevant to the role of an HHA

T – Timebound – for the next 6 months

Ms. Smith is diagnosed with arthritis and reports to experience pain that prevents her from completing personal care (S).  Ms. Smith will have hands on assistance from HHA (R) with transferring into shower, washing her entire body, drying off, getting dressed or undressed, and with brushing her teeth and hair once per day 7 days per week (M, A) for the next year (T).

PERS example: goal is to have assistance if they fall when their HHA or informal support are not home.

S – Specific – Ms. Smith has fallen 3 times in the past month when she was home alone

M – Measurable – Ms. Smith will wear her PERS unit when she is alone from 3p-8p every evening

A – Attainable – Ms. Smith can be wear a PERS unit at any time

R – Relevant – the purpose of a PERS unit is to call for assistance

T – Timebound – for the next year

Ms. Smith has a history of 3 falls in the month prior to the assessment and is diagnosed with arthritis and uses a walker for all mobility (S).  Ms. Smith is alone from 3p-8p every day (M) after her HHA leaves and before her informal support returns home and requires a PERS unit to be able to access emergency assistance (R) at this time every day (A) for the next year (T), should a fall take place.

Transportation example: goal is to go to the community/senior center more often to improve socialization

S – Specific – Ms. Smith is diagnosed with depression and reports having not left her house in months

M – Measurable – the community center has bingo at least once a week

A – Attainable – Ms. Smith is mentally and physically capable of using public transportation

R – Relevant – Non-medical transportation is able to provide transportation to the community center

T – Timebound – for the next 3 months

Ms. Smith is diagnosed with depression and reports she has not left her home in the past few months which is making her feel worse. Ms. Smith will receive a zone 2 Septa transpass and will use it to get to and from her community center at least once a week for bingo at her community center for the next 3 months.

You can practice building SMART goals with this:

  • 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 
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