Keeping track of your goals
Version 3, December 2024
© Caring Futures Institute, Flinders University
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Photography by April Pethybridge , Manuel Meurisse, gryffn m, Megan Clark and Photoholgic; used under licence from Unsplash.com
Having a plan of how to live with a chronic condition can help you think about what you can live with and what you can cope with along the journey.
A care plan is an agreement between a person and their health care team that can help them both manage health and wellbeing from day to day. A good care plan is owned by you and includes goals that matter to you.
Goal setting is an important part of care planning. Setting realistic goals can help you, your health care team, and your supporters agree on what matters most and decide on the best course of action.
My Wellbeing Journal came about because a dedicated group of people wanted to improve conversations between health care professionals, carers, and people living with chronic health conditions.
The journal has been co-designed by consumers, carers, and clinicians from Adelaide, South Australia, and researchers from the Caring Futures Institute, Flinders University. We are thankful to everyone who had input in the creation of this journal.
The pages of this journal have been specially designed to help you discuss and keep track of your health and wellbeing goals. The steps in this journal can help improve the communication and interactions with your doctor and health care team.
Three ways this journal can help:
• it is your personal record of your health and wellbeing goals
• it helps you think about and prioritise how your goals match up with your health care
• it supports conversations with your health care team about your goals and preferences.
You can ask a family member or your health care provider to help or you can complete the journal entries on your own.
These pages are here to help you keep track of important details about your health. You can share this information with your health care team if you want. Use these pages to write down important details that will help you and your health care team.
My name:
Date of birth (day/month/year):
My address: Phone number:
Preferred language (e.g., English, Vietnamese):
Name:
Relationship (e.g., family, friend, carer):
Phone number:
Name: Phone number:
Address:
Main Doctor (GP)
Other healthcare providers (e.g., specialists, allied health)
Name:
Role (e.g., heart doctor, physiotherapist):
Phone number:
These pages can help you and your health care team get the important information you need during appointments, especially when discussing your care goals and preferences.
My medicines
List your current medications, including any over-the-counter supplements or vitamins you take regularly.
Allergies or reactions
Please write down any allergies you have, or things that make you feel sick or uncomfortable.
Write down any important health events, surgeries, or diagnoses you feel are important for your health care team to know about.
diabetes, surgery)
medicine, physiotherapy)
List any conditions you deal with all the time.
went well, still need care)
Your care network includes the people who support you and the people you may support. This network is important because it can make life with a health condition easier. It includes family, friends, neighbours, and healthcare providers who help you with your health and wellbeing.
A care network means you have people to rely on to help navigate and manage your health and wellbeing.
It can help in different ways, such as:
• giving emotional support, like being there when you need to talk
• helping with daily activities, like cooking, driving, or reminding you to take your medicine
• sharing advice or information, especially if they have similar health experiences
• offering medical support, like doctors, nurses, or other health professionals.
Your care network is unique and can change over time. Some people may support you regularly, while others help occasionally.
To make your network stronger, you can:
• share your health needs and plans with the people close to you
• ask for help when you need it and accept support when offered
• keep track of who is part of your network and how they help you.
The circles on the next page help you see who is most important in your care network. This is called a care network map.
It has three circles:
1. Innermost circle
People who help you the most, like close family or friends.
2. Middle circle
People who help often, like neighbours or community volunteers.
3. Outermost circle
People who help sometimes, like distant family, support groups, or health programs.
How to use the circles
Write the names of your contacts in each column. People in the innermost circle are the ones who support you the most, while those in the outermost circle help you occasionally. This map shows the support you have and may help you and your health care team understand your needs better.
your care network
As life changes, so may your care network. Use this page to:
• add new people or groups who start supporting you
• update any changes in who helps and how they support you
• think about who else might be able to help if you need extra support.
Your care network is a valuable resource. Remember that each person in your network plays a special role in helping you with your health and wellbeing.
Care preferences are the choices and needs that make your care right for you. These are things that make you feel respected and comfortable. Care preferences include how you like to get help, who you want around, and what matters most in your life. Sharing your preferences helps care providers understand you better.
Why care preferences matter
Recording your care preferences tells others what is important to you when they help with your health. When care providers know your preferences, they can give you the support you want and need. This can help you feel more comfortable and respected.
Examples of care preferences
Here are some things to think about for your care preferences:
Communication – how do you like to get information? (e.g., clear language, brochures, written notes)
Making decisions – do you want to make decisions with your health care team, or do you prefer more guidance?
Where you get care – where do you feel best getting care? (e.g., at home, in a clinic)
People who support you - Who do you want to be part of your care, like family or friends? You can refer to your care network map (page 15)
Life story – are there important experiences or values you want your care team to know about?
Writing down your care history, care network, and care preferences creates a “care biography”. This is like a story of how you want to be cared for, based on what is important to you. Your care preferences can help your health care team understand what matters to you. Use the spaces below to write down what’s important to you in each area.
you value
Think about what matters most in your life and health care (e.g., privacy, independence, respect).
What I value:
Write about what is most important to you in your care.
How you want help
Describe how and when you like to get support. Include any cultural or spiritual preferences you’d like your health care team to know.
How I like to get support:
Write about the kind of help you prefer and any important beliefs or traditions.
experiences
Some life experiences shape our preferences for care. Think about any major events, experiences, or challenges that are important for your health care team to know about.
My important life experiences
Write about experiences that affect how you want to be cared for.
Special requests
You may have routines or specific requests that make you feel safe, comfortable, and cared for. These can help your health care team give you the best support.
My special requests:
Write down any routines, activities, or other requests that are important to you.
How to share your care preferences:
• talk with your health care team about what matters most to you
• share your preferences with family or friends who help with your care
• review and update your care preferences as your needs change.
STEP 2
Goal setting is a process that begins with the person, their supporters, and their health care team first establishing and agreeing on realistic health and wellbeing goals.
Your goals should be shaped around what matters most to you. Identifying what matters in your life and health can help you think about your priorities and talk about your goals with others.
Important parts of your life could include:
• physical health (e.g. physical activity, sleep, eating)
• managing your care (e.g. test results, reviewing medications)
• mental health (e.g. emotional wellbeing, social support)
• keeping well (e.g. immunisation, health screening)
• staying connected (e.g. volunteering, spending time with friends)
• enjoying life (e.g. doing hobbies, attending social events).
The next page will help you start thinking about goals that relate to different areas of your health and wellbeing.
There are different types of goals. A person’s goals might be based on symptoms or disease-related issues, such as reducing pain or sleeping better. They might also be based on functional goals, such as being able to walk to the shops, or a person’s fundamental values, hopes, and priorities in life, such as continuing to live at home independently.
A person’s health and wellbeing is made up of a lot of parts that can change over time. To better understand your health condition, there are not just physical aspects to consider, but also mental, emotional, and social aspects.
Intellectual (creativity, curiosity, mental stimulation)
Emotional (positive feelings, satisfaction, confidence)
Physical (exercise, proper nutrition, sleeping, sexual health, substance use)
Social (positive relationships, social networks, stability, connectedness)
Spiritual (beliefs, principles, values, seeking meaning and purpose)
Vocational (fulfilment in work, making a positive difference within organisations and communities where we work and live)
Environmental (how the environment influences health and wellbeing)
A chronic condition, also called a chronic disease, is one that takes a long time to go away, or one that comes back again.
Common chronic conditions include arthritis, asthma, back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, mental health conditions and osteoporosis.
Many chronic conditions need special care and treatment for a long time. Once they occur, they can last for a lifetime. Chronic conditions become more common as people get older. This means that there is a need for people to agree on a plan of care with their family, carers, and health care team.
You can take an active role in managing your chronic condition. Reducing risk factors can help prevent some chronic conditions. You can work with your health care team to create a plan to manage your health and improve your quality of life.
Many people living with chronic conditions do not have only one condition; they have two or more chronic conditions at one time.
People with two or more chronic conditions often have complicated health issues, find it difficult to do everyday activities, and have worse overall quality of life. These people might need to take a lot of medications and attend numerous medical appointments. They might feel like their care is not joined up and that they are not treated as a whole person.
When dealing with several chronic conditions at once, it is important to focus on what matters to the person, and all the conditions they have, rather than a single disease.
Whole person care takes into account your physical, social, and mental wellbeing. It focuses on your needs, preferences, and goals and ideally includes your family and carers.
Successful goal setting involves the person, their family, and their health care team planning how they will work together to achieve the agreed goals. It is a process that allows the person and their team to proactively create a plan of care.
A goal can be anything that you want to achieve through your health care. Thinking about what matters to you (page 20) can help you to discuss things you want to be able to do that reflect what is important to you.
A goal is:
• meaningful – it is based on what matters to you
Setting goals puts you in control of your health and care. Just by writing down your goals you are actively acknowledging what matters most to you in your life. STEP 3
• time-bound – it can be accomplished in a specific timeframe
• specific – it has clear milestones and measures of success
• realistic – it is something that you are able and willing to do keeping in mind your current health and supports
• flexible – it can be reviewed and changed over time.
to set achievable goals
Three tips for setting goals:
1. Set goals you can achieve
When you are setting goals, it is important to begin with goals that are realistic considering your current mindset, motivation levels, abilities, and supports. Setting realistic goals makes sure you are using your time and resources well and helps keep you motivated.
2. Think about what motivates you
Part of the process of setting goals should be deciding what motivates you and what your values are. Your goals should feel worthwhile and give you a sense of pride when you achieve them.
3. Reflect and adjust
To make sure your goals are achievable, each one should be reviewed regularly with your family, carers, and health care team. You might need to adjust your plan to make sure you can reach your goals. Remember that your goals will change as time goes on.
STEP 4
Good communication can help you, your family, and your health care team create the best possible plan for you.
Your health care team can listen and provide you with options that will help you meet your goals. The more you can communicate with your health care team, the better they can match up your care with your goals and current situation.
Communication tips:
• voice your wishes – let your health care team know about your preferences and what help you might need
• be specific – try to be as specific as possible about your wishes, including things you are unable or unwilling to do as part of your health care
• ask questions – when your health care team discusses activities or treatment options, ask how they might affect different aspects of your life and health.
You may find the prompts on the next page helpful to think about the topics you would like to talk about or questions you may have.
My health and what to expect in the future:
• what is currently happening with my health and care?
• what can I expect in the future?
• what is the best-case and worst-case scenario?
My treatment options:
• what options are available to treat my health condition?
• what are the aims of the treatment?
• what are the pros and cons of the treatment?
• what do these advantages/disadvantages mean for my other health conditions?
• how much will it cost?
Treating my symptoms:
• what options are available to manage things like pain, nausea, stress, or anxiety?
My life and wellbeing:
• how can I make the most of my life living with my health conditions?
• are there any lifestyle changes I could make to help me make the most of my life, living with my health conditions?
My support system:
• what supports are available for me?
• what supports are available now and in the future for my carer, my spouse, or my family?
• are there any services that would be useful for me or my carer to contact?
Date:
My overall quality of life right now
Are any of these things a source of stress?
(choose or write down your own)
Being active
Feeling tired
Sleep
Falls or balance
Eating well
Weight
Medications
Pain
Other (please specify):
Depression
Anxiety
Feeling lonely
Vision
Hearing
Memory changes
Substance use
Smoking
How this affects my life:
My house
My neighbourhood
My finances
Family and friends
Caring for others
Work or volunteering
Transport/getting around
What I hope my health care team can do for me:
Something I would like to discuss with my health care team:
Questions for my health care team:
I spoke with:
On: / /
Notes:
One goal I want to focus on this month Time frame
Short term (1-12 weeks)
Long term (3-12 months)
Importance of goal
Difficulty of goal (low) (moderate) (high)
Best outcome:
Expected outcome:
Worst outcome:
One goal I want to focus on this month Time frame
Short term (1-12 weeks)
Long term (3-12 months)
Importance of goal
Difficulty of goal (low) (moderate) (high)
Best outcome:
Expected outcome:
Worst outcome:
One goal I want to focus on this month Time frame
Short term (1-12 weeks)
Long term (3-12 months)
Importance of goal
Difficulty of goal (low) (moderate) (high)
Best outcome:
Expected outcome:
Worst outcome:
Reflecting on my progress this week:
(least satisfied) (most satisfied)
Goals I worked on this month
How I am progressing with these goals
Short term (1-12 weeks)
achieved as expected partly achieved no change
Long term (3-12 months) achieved more than expected
Goal 1
Goal 2
Goal 3
Goals I am focusing on next month:
Challenges I need to deal with in the next month:
How I might overcome these challenges:
Use these pages to record the contact details of your health care team and other people you can call if you need support. Name: Phone: Email: Address: Name: Phone: Email: Address: Name: Phone: Email: Address: Name: Phone: Email: Address:
Name: Phone: Email: Address: Name: Phone: Email: Address: Name: Phone: Email: Address: Name: Phone: Email: Address: Name: Phone: Email: Address:
All the references, articles, and websites that we used to create this Journal can be found at our linktree – accessible via the QR code.
My Wellbeing Journal was developed by the Caring Futures Institute at Flinders University in partnership with the Australian Association of Gerontology, Ecocreative, Torrens University Australia, the South Australian Health and Medical Research Institute, Health Translation SA and the University of Manitoba.
The Journal was written by Michael Lawless with assistance from Matthew Wright-Simon, Maria Alejandra Pinero de Plaza, Rachel Ambagtsheer, Timothy Schultz, Rachel Milte, Lucy Lewis, Mike Newman, Lyn Whiteway, Marilyn von Thien, Mandy Archibald and Alison Kitson.
This Journal was designed by Freerange Future in partnership with Michael Lawless. We would like to thank India Koning and the team at Freerange Future.