Setting Goals and Action Steps

For each of the four sections of the Care Plan, the Care Team works with the client to generate goals and the specific action steps necessary to achieve these goals. It is recommended that the goals included in the Care Plan be “SMART.” SMART goals make it easier for both the client and the Care Team to know if progress is being made and to provide more opportunities to celebrate success.

What does SMART mean?

Specific – Who is involved and what exactly do you hope to accomplish?

  • Use only one verb per objective so that only one action or behavior is being measured.
  • Use action verbs that clearly document the desired outcome. Avoid verbs that can be vague, such as “understand,” or “know.”

Measurable – Can the goal be measured? How much change is expected?

  • By focusing on how much change is expected, the goal serves as a reference point for whether or not the goal has been met.

Achievable – Can the goal be accomplished in the proposed timeframe with the available resources and support?

Realistic – Does the goal address the problem? Will the goal have an impact on the problem?

Timely – Does the goal propose a time frame for when it will be measured or met?