Medica SMART Goal Example Guide

What is a SMART GOAL?

Specific What exactly needs to be accomplished?
Why does the member want to accomplish this goal?
Measurable How will we know when the member has succeeded?
How much change needs to occur?
How many actions will it take?
Attainable Does the member have the resources to achieve this goal?
Is the goal a reasonable stretch?
Is the goal likely to bring success?
Relevant Is it a worthwhile goal?
Will it be meaningful to the member?
Can the member commit to the goal?
Time-Bound What is the deadline for reaching this goal?
When will the member begin to take action?
➢ Use each member’s name or “I” in goal statement to make goals more person-centered.
➢ Personalize goals for members and their specific situation(s).
➢ Don’t use abbreviations.
➢ Do not “bunch” multiple goals into one.
➢ Be sure to carry over identified needs or concerns from the assessment to the support plan, or
document why you did not.

SMART GOAL EXAMPLES:

ADL Deficiency » I will have Home Health Aide service in place for bathing assistance by June 1.
» I will self-report receiving appropriate assistance from my facility staff for transferring
though target date.
Asthma » I will self-report having an Asthma Action Plan in place by next review.
» I will self-report having asthma medications in their home by next review.
» I will self-report appropriate inhaler use by next review.
» I will self-report taking medications as prescribed by provider by next review.
Behavioral » I will be able to list at least three coping skills by my next review.
Health » I will establish care with Behavioral Health therapist by target date.
» I will address concerns about my depressed mood with my provider by the next review.
» I will self-report taking medications as prescribed by provider by next review.
» I will self-report reaching out to at least one member of my support system for social
contact each day by next review.
» I will self-report following through with appointments with their new ARMHS (Adult
Rehabilitative Mental Health Services) worker by the next review.
» I will tell my provider when I have feelings of wanting to give up by the next review.
» I will participate in 1 activity per week that I enjoy over the next year.
Caregiver » My caregiver will reach out to a support group by target date.
Support » My caregiver will accept respite by next review.
Congestive » I will self-report checking my weight daily as recommended over the review period.
Heart Failure » I will be able to identify red flag symptoms by target date, such as weight gain, shortness
of breath and swelling.
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» I will verbalize my understanding of when to call my primary care provider as related to
my red flag symptoms by their next review.
» I will self-report taking medications as prescribed by provider by their next review.
COPD » I will discuss my COPD action plan with my primary care provider by next review.
» I will verbalize and demonstrate correct use of inhalers by next review.
» I will self-report taking medications as prescribed by provider by their next review.
Dementia » I will have a supervision plan in place by target date.
» My caregiver will consider respite options by next review.
Dental » I will self-report preventive dental screening by target date.
» I will self-report seeing my dentist for dental pain by quarterly follow up.
Diabetes » I will walk two times per week for 15 minutes by the next review.
» I will self-report having A1C checked by the next review.
» I will self-report podiatry check by the next review.
» I will self-report checking blood sugars as recommended by my provider at next review.
» I will self-report taking medications as prescribed by target date.
ER Use » I will self-report using the Nurse/Care Line before going to the Emergency Room over the
review period.
» I will have a list of nearest urgent care providers by next review.
» I will self-report scheduling appointments with my primary care provider every 3 months
to discuss my ongoing health concerns instead of using the Emergency Room for non-
emergency issues by target date.
Falls/Mobility » I will self-report 0 falls over the next year compared to last year when I had two falls.
» I will self-report daily use of assistive device by next review.
» I will self-report any falls to provider, caregivers and Care Coordinator by next review.
» I will remove all throw rugs in my home by next review to decrease falls risk.
» I will accept grab bars in my home by the next review.
» I will complete a physical therapy assessment within the next 3 months.
» I will accept Personal Emergency Response System by next review.
Frequent » I will follow up with my provider as recommended by target date.
Hospitalization » I will self-report taking medications as prescribed to reduce the need for hospitalization
by target date.
Health Care » I will decide who I would like to list as my healthcare agent when my care coordinator
Directive contacts me for my semi-annual check-in.
» I will self-report that I have completed my Health Care Directive document by target
date.
Hospice » My caregiver will report adequate support from hospice team at next review.
Housing » I will self-report I have obtained secure and safe housing within the next 6 months.
» I will self-report that I have toured 3 customized living facilities within the next 3 months
with the goal of moving to supportive housing.
Hypertension » I will report performing blood pressure checks as recommended by my provider by next
review.
» I will accept a blood pressure cuff for home checks of blood pressure by target date.
» I will have a system for recording blood pressure readings to bring to my primary care
provider by target date.

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» I will self-report taking blood pressure medications as prescribed by provider by my next
review.
Medication » I will self-report taking medications as prescribed by next review.
» I will accept weekly help setting up my medications over the next year.
Nutrition » I will maintain by weight of XXX by receiving home-delivered meals weekly over the
review period.
» I will meet with a nutritionist in the next 3 months to help with weight loss.
» I will address food insecurity concerns by contacting Second Harvest Food Bank by my 3
month check in.
Pain » I will decrease pain by 1-2 points on a scale of 1-10 by target date.
» I will self-report taking pain medication as prescribed by provider by next review.
» I will visit my pain clinic quarterly by target date.
» I will self-report visiting the provider who manages my pain medications by the next
review.
Physical » I will go to the YMCA twice per week over the next year.
Activity » I will improve my mobility by walking the hallways for 10 minutes each day over the
review period.
» I will complete exercises as recommended by my Physical Therapist daily over the next 6
months.
Preventative » I will have an annual preventive physical by December.
Health » I will establish with a new Primary Care Provider in the next 6 months.
» I will self-report making an informed decision about completing a colonoscopy by goal
target date.
» I will complete a vision exam by target date.
» I will self-report that I have called Delta Dental to seek help finding a dentist within the
next 3 months.
» I will discuss the Shingles vaccine with my primary care provider and receive as
recommended by next review.
» I will discuss all needed preventive screenings with their primary care provider by goal
target date.
Safety » I will self-report that I understand risks of refusing services and will notify Care
Coordinator by target if not met.
» I will report following my emergency back up plan in an emergency by the next review.
Socialization » I will continue to attend my adult day program 3x/week for socialization over the next 12
months.
» I will self-report that I have attended church services monthly as desired by target date.
» My group home staff will report that I have participated in 1 community activity monthly
by next review.
Substance Use » I will reduce cigarette smoking to half pack per day by target date.
» I will self-report attending substance use support group weekly through review period.
Transportation » I will address my need for specialized transportation with my doctor within the next
month.
» I will self-report that I have attended all scheduled rides for medical appointments over
the next 6 months.

© 2024 Medica Rev. 11/2024