Rehabilitation & Recovery Goals

Skip anything

Every question is optional. No one has to retell painful events, name a diagnosis, or choose a religion or identity to begin.

Pause or stop

Stop at any point. Nothing is sent anywhere, and nothing is shared unless the person chooses it in the sharing review.

Whose words

Record who said each thing: the person, a caregiver or surrogate, or a professional. A caregiver's needs get their own field.

Support to take part

Extra time, a quieter place, pictures, an interpreter or a trusted person can help someone say what matters. Ask what helps.

Barriers are not preferences

Cost, travel, work, housing, caring for others and digital access are written down as barriers, not as what the person wants.

Meaning, religious or not

Hope, purpose, faith, relationships and identity can be part of the conversation if the person wants. None is assumed.

• Physiotherapist: Movement, strength and mobility goals.
• Occupational therapist: Daily activities, work, home changes and equipment.
• Speech and language therapist: Communication and swallowing, where needed.
• Rehabilitation physician or nurse: The medical side of recovery and the overall plan.
• Social worker: Benefits, return to work and community support.
• Peer mentor: Lived experience of disability or recovery, where such roles exist.
• Chaplain or spiritual-care provider: Meaning, distress, hope and relationships, for people of any faith or none.
• Interpreter or communication specialist: Language and communication support so the person's own words come through.
• People the person chooses: Family, friends, or a community or faith contact, only if the person wants them. Never assumed safe, available or wanted.

Roles, titles and training differ by country and service. Not every role exists everywhere.

A purposive sample chosen for contrast, not a ranking or a representative survey: Global, Norway, Canada, Brazil, Uganda, India, China, Saudi Arabia, New Zealand. Each example states what its source establishes and what it does not. Policy on paper is not proof that a service is available.

• Global · Guidance · 2023

  WHO's package of interventions for rehabilitation says rehabilitation plans are tailored to an individual's needs and based on initial assessment, goals and preferences, so they differ for each person and along the continuum of care.

  What others could learn: A rehabilitation plan can start from the person's own goals and preferences, recorded at assessment and revisited as the person moves between phases of care. The same package lists carer and family training and support among self-management interventions.

  Conditions, limits and source

  Conditions that matter:

  Needs an initial assessment and a trained rehabilitation workforce. The package is built so interventions can be delivered in primary care and community settings when multidisciplinary rehabilitation is unavailable. WHO frames rehabilitation as an essential health service people should reach without financial hardship.

  Cannot be inferred:

  Does not show that goal-based plans improve outcomes. Does not show how many services work this way. Does not say whose goals prevail when the person and the team differ, or how goals should be elicited.

  Limits:

  Technical guidance for ministries of health and planners, not an evaluation of any service. The interventions are described as essential and feasible in most low- and middle-resource settings, not exhaustive. Module 1 mentions the person's goals and preferences once, in this sentence, and does not describe how goals are elicited or recorded.

  Source: World Health Organization, Package of interventions for rehabilitation: module 1: introduction (Section 2.2 'Description of interventions in the Package of interventions for rehabilitation', printed p. 6 (PDF p. 18); Box 4 on the same page lists carer and family training and support under self-management interventions). Where: Global. Population: People with health conditions that need rehabilitation, across the life course. Published 2023-07-06; retrieved 2026-10-11.

• Global · Measured outcome · 2022

  WHO's 2022 global report on assistive technology says survey-based estimates of access, meaning the share of people with a need whose need is met, varied from 3% to 90% across countries.

  What others could learn: Access to assistive products includes the supporting services that match a product to the person's needs and environment so they can do what they wish to do. The report adds that a person's assistive technology needs and related goals will likely change over a lifetime, so a rehabilitation conversation could revisit what the person wants to do, what they use now and what they can reach.

  Conditions, limits and source

  Conditions that matter:

  Access depends on legislation, a public budget or financing for users' costs, a trained workforce for assessment, product range and supply chains. The report says almost all of the 70 Member States that completed its system survey had legislation and a responsible authority, yet large service and workforce gaps remained.

  Cannot be inferred:

  Does not name which countries sit at 3% or 90% in this record. Does not compare countries. Does not show outcomes for people who receive products. Survey methods and definitions of need vary.

  Limits:

  Self-reported survey data. Access here means need met, not the quality or fit of products. This record uses the executive summary; country-level values were not extracted. The report notes large gaps in services and trained workforce, especially for cognition, communication and self-care, and that need and access vary with the Human Development Index.

  Source: World Health Organization; United Nations Children's Fund (UNICEF), Global report on assistive technology (Executive summary, 'Measuring access to assistive technology', printed p. x (PDF p. 12); lesson text at Section 1 'Paths to accessing assistive technology', printed p. 15 (PDF p. 31)). Where: Global. Population: People who would benefit from assistive products (more than 2.5 billion, per WHO and UNICEF estimate). Published 2022-05-16; retrieved 2026-10-11.

• Norway · Reported experience · 2016

  Fifteen people with stroke-induced aphasia interviewed in Norway described being pleased with services, vagueness in language rehabilitation, personal goals that exist, and a desired level of participation in goal setting.

  What others could learn: People with aphasia can state personal goals and how much they want to take part. The authors suggest asking about goals more than once across the rehabilitation journey, asking how the person prefers to take part at each stage, and using existing communication and collaborative goal-setting tools.

  Conditions, limits and source

  Conditions that matter:

  Therapist time for collaboration and communication supports; the authors call for both. Details of the Norwegian service setting beyond the abstract were not retrieved.

  Cannot be inferred:

  Not representative of people with aphasia in Norway or elsewhere. Does not show that more participation in goal setting improves language or other outcomes (the authors call for further research on outcomes). Includes only people able to take part in interviews.

  Limits:

  Abstract only; the publisher site (tandfonline.com) was unreachable. Recruitment sites, time since stroke and aphasia severity are not stated in the abstract. Satisfaction and participation preferences are what 15 people reported, not measured. The authors' implications for practice are recommendations, not a tested intervention.

  Source: Disability and Rehabilitation (Berg K, Askim T, Balandin S, Armstrong E, Rise MB); abstract via PubMed, Experiences of participation in goal setting for people with stroke-induced aphasia in Norway. A qualitative study. (Abstract, Results (Disabil Rehabil 2017;39(11):1122-1130)). Where: Norway. Population: Adults with stroke-induced aphasia (n=15) who had received language rehabilitation. Published 2016-06-13; retrieved 2026-10-11.

• Canada · Service in operation · 2023

  A participatory project in Northwestern Ontario developed a community rehabilitation worker program whose stated goal is to train local workers, familiar with local languages and cultures, to provide rehabilitative services for First Nations elders.

  What others could learn: Where rehabilitation is not available in an elder's first language within the home community, training local workers can bring it closer. The abstract adds that participants stressed culture, spirituality, traditions, local language and returning elders to traditional and community activities in both the curriculum and rehabilitation efforts.

  Conditions, limits and source

  Conditions that matter:

  A partnership of four First Nations, three Indigenous health organizations, three rehabilitation organizations and two academic institutions, working under the OCAP principles (ownership, control, access, possession); the program is co-facilitated with a First Nations Elder, and a college welcomed its first cohort in March 2022. The project team asked governments to fund elder-focused transportation, mental health support and gathering places.

  Cannot be inferred:

  Not evidence that the program changes elders' function or helps them reach their goals. Does not describe all First Nations or Indigenous communities in Canada. Not proof the program still operates. Built with and for specific communities; not a template to copy without local partnership.

  Limits:

  Abstract only; the journal site and doi.org were unreachable. The abstract reports curriculum feedback and a first cohort starting, not outcomes for elders; implementation is to be evaluated with the first cohort. Authors are project partners. The abstract does not give numbers trained or say whether the program continues.

  Source: Rural and Remote Health (Moller H, Baxter R, Denton A, et al.); abstract via PubMed, Outcomes from a collaborative project developing and evaluating a community rehabilitation worker program for Northwestern Ontario First Nations. (Abstract, Conclusion (Rural Remote Health 2023;23(3):7809)). Where: Canada (Northwestern Ontario). Population: First Nations elders in treaty territories 5, 9 and Robinson-Superior; 101 curriculum evaluation participants. Published 2023-07-11; retrieved 2026-10-11.

• Brazil · Reported experience · 2016

  In interviews with 101 people with severe disability after traffic crashes and 19 health professionals in Natal, Brazil, service barriers to physical rehabilitation included bureaucracy, few services, little information and no guidelines linking hospital and outpatient care.

  What others could learn: Access barriers sit in service design as well as in a person's circumstances. A service could record at discharge what rehabilitation exists, how to reach it, what it costs and how far it is, and who coordinates the step from hospital to outpatient care.

  Conditions, limits and source

  Conditions that matter:

  Public referral and regulation rules, the supply of rehabilitation services and professionals, transport and cost. The authors link better access to expanding services, standardizing referral practices and giving patients information about continuity of care and their health needs.

  Cannot be inferred:

  Not representative of Brazil or of people with other kinds of injury or illness. Does not show current service availability in Natal. Does not show which barrier matters most.

  Limits:

  Abstract only; the publisher site was unreachable. One city; participants were identified from one emergency hospital's database. The barriers are those named in interviews, not measured frequencies. The authors say their theoretical model of causes must still be tested.

  Source: Disability and Rehabilitation (Sousa KM, Oliveira WI, Melo LO, Alves EA, Piuvezam G, Gama ZA); abstract via PubMed, A qualitative study analyzing access to physical rehabilitation for traffic accident victims with severe disability in Brazil. (Abstract, Results (Disabil Rehabil 2017;39(6):568-577)). Where: Brazil (Natal, Northeast). Population: People with severe disability after traffic crashes (n=101) and key informant health professionals (n=19). Published 2016-03-17; retrieved 2026-10-11.

• Uganda · Reported experience · 2023

  In rural Masaka, Uganda, people living with stroke, who were often interviewed with caregivers present, expressed a clear lack of opportunities for professional rehabilitation, attributed to lack of money and availability.

  What others could learn: Rehabilitation planning for a person at home also plans for the caregiver. The authors conclude that stroke interventions should support caregivers as well as the person, and suggest home rehabilitation approaches that build health literacy; participants and caregivers described cost, transport and distance as barriers.

  Conditions, limits and source

  Conditions that matter:

  Cost of transport and treatment, distance from facilities, and out-of-pocket fees even where basic hospital care is free of charge. Caregivers seemed more commonly to move into the survivor's home. Assistive aids were costly, and walking sticks were commonly made locally.

  Cannot be inferred:

  Not representative of Uganda or of rural Africa. Does not show how many people lack rehabilitation. Does not show that caregiver support improves recovery.

  Limits:

  Fourteen participants in one rural area. Interviews were translated and analyzed by researchers from outside Africa, though the team included co-authors with local knowledge; data are missing on one participant's characteristics. Caregivers were present in most interviews and sometimes helped participants recall events.

  Source: BMC Public Health (Timm L, et al.), Struck by stroke - experiences of living with stroke in a rural area in Uganda (Results, Theme 4 'Interrupted care due to economic constraints'; abstract Conclusions). Where: Uganda (rural Masaka). Population: Fourteen adults living at home after stroke; caregivers were present in most interviews. Published 2023-06-05; retrieved 2026-10-11.

• India · Reported experience · 2019

  In interviews, 30 people with stroke in India expressed preferred outcomes such as using eastern toilets, sitting on the floor, eating with the right hand, walking long distances and using public transportation.

  What others could learn: Ask what the person wants to be able to do in their own home and community, rather than relying on a standard list of daily activities. The authors also advise telling apart activities a person cannot do from ones they have no need or wish to do.

  Conditions, limits and source

  Conditions that matter:

  Participants attributed their preferences to the physical environment (natural and built), family structure and living conditions, and cultural values, norms and practices. Goal setting needs time to ask, and measures chosen to match what the person wants to do.

  Cannot be inferred:

  Not representative of India or of any group within it. The authors conclude that outcome preferences of patients with stroke are not universal, so these goals do not transfer to other settings. Does not show that goals set this way improve recovery.

  Limits:

  Abstract only; the publisher site was unreachable. Recruitment sites are not stated in the abstract, so the geographic spread is unknown. Preferences are what 30 people said in interviews. The authors' framework of four domains is their own synthesis.

  Source: Disability and Rehabilitation (Prakash V, Ganesan M); abstract via PubMed, What matters to patients with stroke in India and why: a qualitative study. (Abstract, Results (Disabil Rehabil 2021;43(18):2585-2592)). Where: India. Population: People with stroke (n=30), purposive sample with diverse socio-demographic and disease characteristics. Published 2019-12-27; retrieved 2026-10-11.

• China · Reported experience · 2022

  Fifty community-dwelling stroke survivors in two provinces of mainland China said their rehabilitation demands remained unmet, due partly to limited mobility and the absence of supportive companions and accessible facilities.

  What others could learn: Where facilities are far or hard to use, participants most often recommended home-based rehabilitation: home exercise guidance from professionals or volunteers, door-to-door household support, counseling and home modifications. The authors suggest assessing short- and long-term needs before discharge and matching survivors with services.

  Conditions, limits and source

  Conditions that matter:

  Travel to facilities outside the neighborhood, accessibility of public exercise equipment, companions or volunteers, and who lives with the survivor. Rehabilitation strategies that fit the person's level of disability, per the authors.

  Cannot be inferred:

  Not representative of China, urban or rural. Does not show that home-based rehabilitation works better. Does not describe services in other provinces.

  Limits:

  Fifty survivors recruited from two hospitals and community centers in two provinces; not a national sample. Authors are based in Hong Kong. Demands described as unmet are the participants' own accounts, not a measure of service supply.

  Source: International Journal of Environmental Research and Public Health (Chau JPC, Lo SHS, Butt L, Liang S), Post-Stroke Experiences and Rehabilitation Needs of Community-Dwelling Chinese Stroke Survivors: A Qualitative Study (Abstract; Conclusions section on home-based rehabilitation). Where: China (two mainland provinces). Population: Fifty stroke survivors living in the community; 80% first stroke, 92% living with family or caregivers. Published 2022-12-06; retrieved 2026-10-11.

• Saudi Arabia · Reported experience · 2023

  In interviews with 24 people discharged after stroke rehabilitation in Saudi Arabia, participants reported limited community rehabilitation services after discharge unless they could pay for private therapy.

  What others could learn: Before discharge, ask what rehabilitation the person can reach and afford at home, and who will follow up. The participants suggested strategies to improve rehabilitation within hospital and community, staff needs, access to services and ongoing care.

  Conditions, limits and source

  Conditions that matter:

  Out-of-pocket cost of private therapy, few publicly funded community services, transport to hospital sessions, and social support. Participants named faith, recovery, social support and leisure among facilitators of coping, alongside medical, psychological, social and financial barriers.

  Cannot be inferred:

  Not representative of Saudi Arabia. Does not show how many people lack follow-up. Does not show the effect of a community rehabilitation program; the authors call for developing and evaluating one.

  Limits:

  Two hospitals; transcripts were translated before analysis. A correction notice was published in 2025 (PLoS One 20(5):e0324195); the PubMed record does not describe it and it was not reviewed. Findings are participants' accounts, not a count of services.

  Source: PLoS One (Temehy B, Soundy A, Sahely A, Palejwala Y, Heath J, Rosewilliam S), Exploring the needs of stroke patients after discharge from rehabilitation centres in Saudi Arabian communities: An IPA qualitative exploratory study design (Abstract; Discussion on limited access to services after discharge). Where: Saudi Arabia. Population: Twenty-four adults (15 men, 9 women) discharged from in-hospital stroke rehabilitation within the past three years. Published 2023-09-08; retrieved 2026-10-11.

• New Zealand · Reported experience · 2021

  In a New Zealand qualitative study (8 patients, 8 health professionals), participants found the ADOC iPad app a valuable tool for setting shared rehabilitation goals and said it promoted a patient-centered approach.

  What others could learn: A visual, structured prompt can help a patient and team arrive at goals together, and can change what the team sees as important. The tool is only one way to ask; the authors say it would not suit every patient.

  Conditions, limits and source

  Conditions that matter:

  iPad access, time and user guides; English-language version adapted from a Japanese tool developed for people with any disability, tested before in Japan in occupational therapy practice. Goals are chosen from an illustrated list of activities, so the list's range affects whose goals appear.

  Cannot be inferred:

  Does not show better goal attainment or function. Not a comparison with usual goal setting. Says nothing about use in Japan or other languages in this study. Not evidence for people who cannot use the app.

  Limits:

  Small sample. Patients had to hold a basic conversation in English. Professionals said the app was not suited to patients with severe cognitive impairment or those already clear about their goals, and iPad access and a lack of user guides limited use. The tool's developer is a co-author (declared; no pecuniary benefit declared). Professionals may have been more positive about technology than average. The study did not test clinical benefit.

  Source: JMIR Rehabilitation and Assistive Technology (Strubbia C, Levack WM, Grainger R, Takahashi K, Tomori K), Use of an iPad App (Aid for Decision-making in Occupational Choice) for Collaborative Goal Setting in Interprofessional Rehabilitation: Qualitative Descriptive Study (Abstract, Conclusions; limitations in Discussion 'Strengths and Limitations'). Where: New Zealand. Population: Eight adult rehabilitation patients and eight allied health professionals (physiotherapists, occupational therapists, speech-language therapists). Published 2021-11-18; retrieved 2026-10-11.

• The sourced examples include guidance, measured outcome, reported experience, service in operation. Each quote was matched to the source text; that is not independent expert review.
• The prompts and fictional case are original. They have not been tested with patients, caregivers or clinicians.
• Whether this workflow helps anyone is an open research question.
• Content is in English. Interface translations are not reviewed for this topic.