For people and teams reconsidering an IHS training goal
What should we do when the same IHS goal keeps appearing without useful progress?
Review whether the goal still matters to the person, whether real practice occurred, and whether the approach fits the task and setting. Describe what assistance was used and what got in the way. Then decide with the responsible team whether to keep, narrow, adapt or replace the goal. A repeated goal is a reason to ask better questions, not evidence that the person is unwilling.
Check the person's interest before changing the method
Ask the person whether they still want the outcome. A goal selected months ago may no longer match their priorities, or they may never have understood it in the same way as the team. Explain it in ordinary language and allow a different answer.
Keep disagreement visible. If the family wants one activity and the person prefers another, document both instead of rewriting the person's preference into compliance language. The next meeting should resolve what the person wants to work toward before selecting a more intensive way to pursue someone else's goal.
Check whether practice actually happened
Look at completed opportunities, not only scheduled visits. Was the relevant activity available? Did the person have the materials? Was the worker taught the agreed approach? A record saying “goal addressed” may not show whether the person practiced the intended step.
If sessions were canceled or spent resolving another issue, record that context. Lack of opportunity is different from a skill remaining difficult despite practice. Ask for concrete examples of what the person tried and what assistance was offered rather than drawing conclusions from a checkbox.
Identify the barrier before choosing the change
Use the matrix to organize a review conversation. These are possible explanations to investigate, not diagnoses. More than one can apply, and the person's account may point to a missing category.
| Possible issue | Evidence to look for | Change to discuss |
|---|---|---|
| Goal no longer matters | Person describes a different priority | Replace or reframe the goal |
| Task is too broad | Notes cover many unrelated steps | Select one useful step |
| Practice opportunity is missing | Materials, visits or activities were unavailable | Resolve access and scheduling |
| Approach is inconsistent | Workers use conflicting instructions | Clarify one agreed approach |
| Support need differs from the goal | Person wants ongoing assistance with a familiar task | Review service fit rather than relabeling assistance as training |
Make one proposed revision concrete
Replace “work harder on independence” with a specific revision: a shorter task, a different format, a more suitable time, or a goal the person now chooses. Explain what would change during the next visit and what would remain the same.
DHS distinguishes training from support with existing skills. A review may reveal a different mix of needs. Ask the case manager and provider to address service and plan implications rather than independently changing the type or amount of support. The worksheet records a proposal until the responsible team agrees.
Choose evidence that would help evaluate the revision
Decide what to observe at the next agreed review. If the issue was an unavailable picture list, the first check is whether the list was present and used as intended. If the issue was an unwanted goal, ask whether the new activity matters to the person.
Avoid choosing an arbitrary success percentage merely because it looks measurable. A useful observation explains the task, circumstances, assistance and person's experience. If the team uses a formal measure, ask how it is defined and why it fits this goal. Keep examples and actual results clearly separate.
Record the decision and retire conflicting instructions
Write the agreed decision, who confirmed it, and which version of the goal or practice instructions now applies. Tell relevant workers what changed. Keep earlier records as history where required, but do not let multiple active instructions compete during the next visit.
At follow-up, compare the actual experience with the reason for the change. If access was fixed but the person still dislikes the activity, return to their priorities. A review is useful when it changes the understanding of the task, even if the next decision is to choose a different goal.
IHS goal revision decision record
Use actual observations and the person's account. Mark suggested changes as proposals until the responsible team confirms them.
Download worksheet (.txt)- Current goal
- What is the goal in plain language?
Illustrative entry: Prepare for a chosen community activity.
- Person's view
- Does the outcome still matter to them?
Illustrative entry: Still wants to attend but dislikes the long preparation checklist.
- Practice evidence
- What was actually tried and with what assistance?
Illustrative entry: Several visits covered only part of the list.
- Likely barrier
- What explanation needs checking?
Illustrative entry: Task may contain too many unrelated steps.
- Proposed change
- What specific revision should be discussed?
Illustrative entry: Focus on choosing and packing materials.
- Observation for review
- What would help evaluate that change?
Illustrative entry: Whether the shorter list is available, used and preferred.
- Decision and version
- Who agreed to what and which instructions now apply?
Illustrative entry: Record team confirmation before treating the revision as active.
An optional discussion tool, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.
Worked example: narrow the task instead of judging motivation
A goal to “prepare independently for all outings” remains unchanged across several reviews. The person says the checklist is too long and mostly covers things they already manage. Notes show that visits rarely reach the part they want help learning. The team discusses a narrower goal about selecting materials for one chosen activity. The next review will examine the short list, actual practice and the person's feedback. The example shows a reasoning process, not evidence that narrowing a goal guarantees progress.
This example is invented to explain the worksheet; it is not a client story or a promised outcome.
Your next step
Bring the person's view and specific practice evidence to a review, then document one clear decision about the goal.
For a conversation with Clemens Health about your Twin Cities location, call (651) 354-1196 or send a referral. Service fit, authorization, and staffing need to be confirmed.
Minnesota resources
State resources explain program rules. The worksheet and examples are Clemens Health planning aids. Links were checked October 5, 2026; follow the current state guidance for eligibility and service questions.