Implementing the Person and Family Centered Care Best Practice Guideline to Improve Interdisciplinary Care Planning for Older Adults using Client Centered Goals
Summary
SE Health formerly known as Saint Elizabeth healthcare is a not-for-profit social enterprise that provides quality home and community care services across Canada in a variety of settings. This includes settings such as private residential homes, residential facilities, and congregate settings just to name a few. SE Health’s mission is to spread hope and happiness amongst clients, caregivers, and providers to have a positive impact on their health and life outcomes. One of the ways that SE has achieved this has been by investing time and efforts to establish person and family centered care as an integral part of daily practice through education and implementation of best practice guidelines as a BPSO organization. This fellowship was focused on the Acute transitions program called Southlake at Home which is also a designated OHT site. This program is a 16-week transitional program from hospital to home where a dedicated interdisciplinary team provides, care and health education to the client and caregivers by providing holistic and comprehensive care. During the 16-week program there is a mid-program care conference where the client, caregivers and providers join to discuss the clients care plan, discuss goals that have been achieved and if there are any barriers to achieving their goals during the program. The client is then given the opportunity to review and adjust their care plan as needed while the provider facilitates and develops the client centered care plan to achieve realistic and optimal outcomes. While also planning for discharge from the program and discuss sustainable options for client to continue to have community supports to stay home safely. In my role as the Transition care lead (and champion lead) I have the privilege to guide, coach, and facilitate an exceptional interdisciplinary team that consists of nurses, personal support workers, rehab, and allied health. The local context for this project was to facilitate the development of the interdisciplinary teams’ skills to create client centered care plans, while implementing Person and Family Centered Care Best Practice Guidelines into their daily practice.
The overall learning goal for this fellowship was to develop my skills and expertise in knowledge translation to facilitate the implementation of the Person and Family Centred Care Best Practice Guideline (PFCC BPG) (RNAO, 2015). Three key elements of knowledge translation: synthesis, exchange, and application of knowledge, served as the framework for this fellowship. Through the fellowship project, I completed activities in each of these areas to improve my leadership, coaching and facilitation skills to better support the practice of interdisciplinary teams. Specifically, to focus activities on enhancing the teams’ execution of care planning using client centered goals. The initial phase of my learning plan was to refresh and develop skills in synthesis of knowledge. The activities included connecting with SE research centre and hospital librarians, performing a literature search, and completing an annotated bibliography. I practiced developing my skills in summarizing and evaluating evidence related to knowledge translation research and person and family centered care research. I created a beginner’s guide to literature search and review with the intention to share these learnings with peers and front-line staff to promote the value of evidence informed practice. I also reviewed the existing SE education and material related to PFCC and developed a repository document that list all the available material for leadership, front line staff and the public. This would inform future work and build on the continuing education needed to sustain PFCC within the organization. Regarding dissemination of knowledge, activities included participating in SE research journal club where the forum allows to share new evidence and receive a peer review and feedback. The evidence is then distributed to leadership within the organization with aim to empower their practice. I also took the opportunity to provide PFCC education (5 module series) to the interdisciplinary transitions teams that included 3 other transition programs. The sessions were engaging and interactive and allowed the exchange of knowledge amongst the different transitions’ teams. I also had the opportunity to apply my knowledge by facilitating some of the mid program care conferences to discuss client centered goals and care plans. I also provided coaching and facilitation weekly during care planning sessions with the interdisciplinary team.
Outcomes
The population served by the Southlake at Home 16-week program is mainly comprised of older adults experiencing medical, functional and/or social risk factors for requiring an alternate level of care, including residential care placement. Each client is given a mid-program care conference and they provided positive comments and feedback. The submitted Nquire data (Nov 2021) for implementation of BPG PFCC showed 80% of persons participating in developing their personalized plan of care and 80% of persons satisfied with their involvement in their planning of care and treatment. (10 clients were interviewed during their mid program care conference) For example, Mr. H. an 83-year-old male living in a retirement home. His goal was to “Use walker more, regain mobility, maintain strength”. He shared that he was able to achieve these goals such as walking outside, playing pool, doing social activities at the retirement home. We discussed what he thought he would need to achieve his goals and what barriers he faced. For example, he was interested in reassessing his home exercise plan as he felt he can do everything already. He also discussed about managing his pain and having trouble with toilet seat being low. He commented that he and his family felt involved in care planning. Care plan was revised for second half of program to include nursing to reassess pain management, rehab team to assess home exercise plan and OT to reassess bathroom safety equipment. His discharge plan was also discussed and agreed upon to send a referral to HCCSS to continue receiving home care services such as PSW. A second example of client centered goal and care plan that resulted in a positive outcome was Ms. W. 81-year-old female who wanted to regain her independence by living on her own. The interdisciplinary team assisted to apply for special priority subsidized housing due to her living situation. Finally, it was confirmed she would be moving to subsidized home on Dec 19 and commented that she achieved her goal with the help of the Southlake at Home team.
There were also positive outcomes experienced among colleagues and staff, organization, and stakeholders because of the fellowship. For example, the interdisciplinary staff who attended the PFCC education presentations provided positive survey feedback regarding the PFCC education series that the fellow presented. There were between 27 -32 multidisciplinary staff who attended which consisted of PSW, Nursing and Allied Health. There were two pre and post survey question answers of note to show positive outcomes. Pre-session question was “On a scale from 1 to 5 (with 1 being none and 5 being expert) how would you rate your competency with the application of person-centred care BEFORE taking this education” Response average number was 3.71. Post session survey question asked, “On a scale from 1 to 5 how would you rate your competency with the application of person-centred care AFTER taking this education (with 1 being none and 5 being expert)” Response average number was 4.5, which showed a marked improvement. Staff rated the sessions as engaging and relevant to their practice, very informative and they were able to identify key learnings, and some would put into practice what they learned. From an organizational perspective my mentor team included a good representation of the different leadership within SE (research, advance practice leads, and operations management). Mentors were very supportive and provided positive and constructive feedback. Also, through networking with different internal teams during the fellowship to complete activities, the response was positive as well. During this fellowship I have had the opportunity to join steering committees related to evidence informed practice, and my contributions were well received. Stakeholders such as LOFT, York region and Hospital partners also expressed interest and provided positive feedback about this fellowship as it could influence future work related to OHT implementation and future OHT fellowship application.
Overall experience
My overall fellowship experience has been enlightening, engaging, positive, empowering, and motivating. It was invigorating to research again and spend time on evidence informed practice and improving my own skills and professional development. I feel more confident in my skills and application of literature review and knowledge translation, which helps me be a better leader to foster the values of evidence informed practice amongst the teams I work with. I enjoyed networking internally and learning about other SE depts such as research team and advanced practice leadership. I was able to build my external network relationships with other community providers such as LOFT, York region, Southlake and RNAO support team. I feel empowered as a champion lead to be able to influence present and future champions to build capacity within SE to implement and improve best practice related to person and family centered care and future guideline implementation. This fellowship has motivated me to continue to grow and develop skills to be an effective champion lead, to sustain post fellowship activities by being an active member in different committees such as BPSO evidence informed practice, OHT steering committee and work groups and participating in a grant proposal as collaborator with SE Research team “Co-designing action-oriented mental health conversations between care providers and aging Canadians in the community”. Overall, this fellowship was a rewarding experience and valuable towards my journey of professional development.
