SMART approach to care plans

The SMART approach to care plans
SMART is a well-known acronym for Specific, Measureable,
Attainable/Achievable, Relevant/Realistic and Time-bound/Timely/Timelimited. It has been used to support systematic planning in many areas
including health, business, and education. It can help you to develop plans
that are clear, can be implemented, and can be evaluated.
Specific: This stresses the need for a specific goal rather than a more
general one. This means the goal is clear and unambiguous; without
vagaries and platitudes.
Measurable: This stresses the need for concrete criteria for measuring
progress. The thought behind this is that if a goal is not measurable it is
not possible to know whether the service user and the team are making
progress toward successful completion. Measuring progress is supposed
to help us stay on track, and experience the positive experience of
Attainable/Achievable: This stresses the importance of goals that are
realistic and also attainable. Whilst an attainable goal may stretch a team
in order to achieve it, the goal is not extreme. That is, the goals are neither
out of reach. When you identify goals that are most important to the
service user you begin to work out ways you can make them come true.
You develop the attitudes, abilities, skills and resources to reach them.
Relevant/Realistic: This stresses the importance of choosing goals that
matter. A bank manager’s goal to “Make 50 peanut butter sandwiches by
2pm” may be specific, measurable, attainable and time-bound but lacks
relevance. Relevant goals support the service user to move forward. A
goal that supports or is in alignment with other goals would be considered
a relevant goal. A relevant goal can answer yes to these questions:
Does this seem worthwhile? Does this match our other efforts/needs?
Is this the right time?
Is it being supported by the right person?
Time-bound: This stresses the importance of grounding goals within a
realistic time-frame. A commitment to a time-frame helps a team focus
their efforts on completion of the goal on or before the due date. A timebound goal will usually answer the question When?
What can I do six months/six weeks from now? What can I do today?
Is the following care plan SMART? What areas are missing or
Instead of: Need = Home help or even Need = Have a fire lit and help with
morning routines
, the need should represent what the action is really
intended to meet. No-one has a need for a Home Help, the need is for
adequate warmth, or cleanliness, or personal care.
The action to meet the need might be:
to have a home help who undertakes certain tasks, or
support for the person to learn to do this, or
to consider a change of heat source, depending on what the
person feels would best support their independence.
Care Plan date:
to improve John’s current situation
1. To help John get back to work OT
2. Refer John to X for help with anger
management CPN
3. Monitor medication CPN
4. Check benefits SW
5. To review the plan in six months CPN
Identifying needs:
Care plans should always identify needs (rather than
services), so the following is an inadequate care plan:

Need Action Responsible
Home help Every day Home help

Accuracy and completeness
The care plan should always be able to be picked up and used by
colleagues if the person coordinating the care is not there, so must include
enough information for someone else to implement the plan.
Unmet needs
It is important that any needs that are identified as part of assessment or
review are included in the care plan. If they can’t be met, this should be
discussed, and the plan should include actions working towards meeting
Good practice example:

Need Action Responsible
Keep warm and get Home help every morning Jo Smith,
Social Worker
up in the morning between 9 and 10 a.m. to
light the fire and help with
personal care


Need Action
Day Hospital Every Thursday for

Write a better care plan:
Goal or outcome:
Need Action Responsible
“Named care coordinators should record any needs the person has
that health and social care practitioners cannot meet. Discuss and
agree a plan of action to address these needs with the person and
their carer.”
NICE 2015 Older people with social care needs and
multiple long-term conditions