Person-centred care is one of the key features of successful integrated care for older people living at home. By adapting to the needs of the user (client), integrated care is able to reduce risks and the level of complexity in a person’s situation. In this article, we discuss 4 activities for the improvement of person-centred care.
These 4 activities are outlined in the Roadmap, a practical representation of the research findings of the European project, SUSTAIN. This collaboration addressed the question, ‘How to improve integrated care for older people in Europe who are living at home?’ Vilans was involved in the research. You can find the Roadmap right here.
Improved person-centred care leads to better integrated care
Person-centred care is about focusing on people’s individual needs, preferences, culture, capabilities and strengths, rather than their illnesses or limitations. When caregivers also influence a person’s wellbeing by paying attention to social isolation for example, risks can be reduced. In circumstances where a user is unable to express his own needs and wishes, a caregiver can still achieve person-centredness by engaging family and informal carers.
Improved person-centred care leads to better integrated care. This is enabled by the following key activities:
1. Communication and active listening – In this way, professionals gain better insight into the user’s health, social, emotional and relational situation. They are able to build a trusting relationship and support the engagement of the patient or his informal carer. Active listening requires fully concentrating on, understanding, responding, and then remembering what someone has said. It involves not just listening with one’s ears, but also with one’s heart and mind to carefully try to understand the person’s needs or concerns. Communication should aim to minimise medical or profession-specific jargon and decrease the knowledge gap between the user and the professional.
For instance, in Austria nurses adjusted their language to suit their clients. Instead of speaking of ‘dementia disease’, they used terms such as ‘forgetfulness’ or ‘reviewing your memory’ when they screened the person for the possibility of dementia.
2. Shared decision-making and co-production of a care plan – Research findings show that shared decision-making and co-production are associated with fewer hospital admissions, fewer days in hospital and lower costs. In shared decision-making it is important that the professional and the user together, fully explore care or treatment options, along with their risks and benefits. The process of shared decision-making also results in the co-production of care plans.
An example from practice: in Catalonia, a care team organised a meeting with users and their carers to present, discuss and validate care plans that had been drafted by the multidisciplinary case conference. This ensured that users were able to participate in their own care planning and therefore accept the actions outlined in the care plan.
3. Relational continuity over time for users – Relational continuity results in trusting relationships between the professional and the user, which promotes empathic, collaborative consultations. It improves the care experience for users, professionals and informal carers. It also enhances the quality of care and contributes to better outcomes. Relational continuity means professionals secure an ongoing therapeutic relationship with the client over time, and across different health and life events. Relational continuity can also be established through a group, provided that this is not compromised in a way that threatens a user’s wellbeing or disregards their wishes and priorities.
For instance, in a Catalonian improvement project, professionals worked on achieving greater visibility of an integrated care team. The user became familiar with the team and the relationship depended less on one specific professional.
4. Supported self-care – Older people’s ability to manage their own care is essential for improved commitment to treatment, use of services, and maintenance of health and wellness. It involves supporting users, carers and their families to take responsibility in managing the user’s own health, wellbeing and care. Professionals can do this by emphasizing the user’s essential role in this and using effective interventions that reinforce self-care initiatives.
An example from practice: at the KV RegioMed Zentrum in Templin, an important goal of the three-week therapy programme is to enable users to manage their own health and wellbeing. Professionals do this by providing an individual therapy plan that is tailored to the user’s specific situation.
In the European project SUSTAIN (Sustained Tailored Integrated care for Older People in Europe) researchers, policy advisors and other partners from eight participating European countries analysed initiatives in the field of integrated care for older people living at home. The Roadmap is their end-product and enables policy and decision-makers to design and improve integrated care in their own community.
The SUSTAIN project was funded under Horizon 2020 – the Framework Program for Research and Innovation (2014-2020).