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Patient and Family Centred Care

Patient and Family Centred Care involves patients, family and the health-care team working together in the planning, delivery and evaluation of health-care services. "It is founded on the understanding that the family plays a vital role in ensuring the health and well-being of patients of all ages."

The Health & Aging Model of Care includes six goals: Quality and Excellence, Patient Safety, Health Promotion and Wellness, Accessibility, Inter-professional Collaboration and Efficiency and Effectiveness. These goals direct our approach to Patient Centred Care.

Information Sharing, Participation, Dignity and Respect, and Collaboration are the four components of Patient and Family Centred Care. These four components ensure that the five key actions of: Assessment and Management, Leadership, Advocacy, Research and Education support our philosophy of quality holistic Patient and Family Centred Care.

Patient and Family Centred Care is associated with a higher rate of patient satisfaction, involvement of family, better outcomes and more cost-effective care.

  • Individual Plan of Care

  • Goal Attainment Scaling

  • Creating a Safe Environment

  • Interdisciplinary team approach to care

Individual Plan of Care

The individual plan of care is based on the admission and ongoing assessments and will include referrals to and interventions as planned by the various team members. The plan of care is integrated with the discharge and/or the long term placement plan. Mutual goals are set with the patient/family and interventions are geared toward rehabilitation and improving the patient's level of functional independence (Goal Attainment Scaling). The information needs of the family and the availability of community resources are assessed and considered at all phases in the plan of care. The plan of care is reviewed by the team at team conferences, in conjunction with the patient/family, and at family conferences.

Goal Attainment Scaling (GAS) is a goal setting and evaluation tool that measures individualized outcomes for geriatric and rehabilitation inpatients. Goals are set in areas where improvement is anticipated. Goals can include mobility, treatment, activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

GAS helps direct the interprofessional team to set achievable goals that are focused on the patient's discharge plan; the tool keeps the team focused on the goals of the patient records the patient progress, and identifies any challenges for discharge.

The GAS tool is initiated for all admissions in the clinical areas of geriatrics and rehabilitation. The GAS is initiated within the first week of admission and then updated weekly during team rounds. The scores are measured on admission, throughout the hospital stay and on discharge from the unit. The team determines the goals after discussion with the patient and/or family, based on what the hope for discharge will be.

Creating a Safe Environment

Creating a special environment that is not only safe but also allows for freedom of movement, mobility and socialization are priorities in unit design and construction. Safer environments can be created by designs which consider the unique needs of the population, and the integration of creative and technological solutions when possible and appropriate. A homelike atmosphere is enhanced by separate dining areas, 'wander' routes, television and social areas, and rehabilitation areas.

Interdisciplinary Team Approach to Care

The patient, family and caregivers are provided opportunities to play an active role in the plan of care and are an integral part of the team by communicating concerns to health professionals, and becoming involved in the patient's health maintenance and functional improvement. All patients are encouraged to be active participants in their care so that they can make independent lifestyle decisions and health choices. The interdisciplinary team will provide patients with complete information regarding their health and, with the patient's permission, discuss this information with their family/caregivers.


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