Jennifer Marie J. Yang, MD

In the last blog post, we tackled communication’s importance in a patient’s active participation in rehabilitation and adjusting to their “new normal” after a life-changing event. The rehabilitation team’s patient-centered care involves communicating information in a timely manner, promoting a supportive environment and building good relationships with the patient and family and delivering both bad news and messages of hope. Part 2 of this topic will deal with a few more tidbits about patient-centered care, and transitioning from hospital to home.

The rehabilitation team is composed of individuals who are experts in their own fields that all work together in reaching a common goal of helping patients get back to living a meaningful life after an injury or disease that has fundamentally changed themselves. Part and parcel of this task is to provide information and education about their condition and “translating” this into day-to-day activities, from basic tasks like eating and dressing to more complex ones like participating in work or hobbies. Patients and families with a clear understanding of their conditions and prognosis are better equipped to cope with the new normal, develop problem-solving skills, improves their sense of control and ability to manage difficult situations (Bamm et al. 2015, Lindahl et al. 2016).

Shared decision-making is a major theme in all patient-centered care. The approach to this in the rehabilitation setting is no exception – especially that the patient’s goals are foremost consideration and of course they will be motivated to participate in therapies when working on something they want to do. In an environment that practices PCC, these goals are not made for the patient but rather with the patient as a partner (Cott 2004; Lindahl 2016; Wain, Kneebone & Billings 2008). While the rehabilitation team members have expertise in what they do, the patient is the expert on their previous conditions, their living situation and their coping mechanisms (Bamm et al. 2015). The team (and patient’s family) is there to guide the patient along the journey, but the journey itself is the patient’s alone.

Finally, some thoughts on going home from the hospital. When patients are discharged from the hospital, they are leaving a supportive, predictable environment in which staff is available 24/7 to another one that may create anxiety for the patient: for example, a house that may not be accessible because they now use a wheelchair, or a situation in which they have to be dependent on others for activities of daily living like bathing and dressing. These examples are not mutually exclusive either. In the inpatient rehabilitation world, we frequently say that discharge planning starts at admission since evaluating the patient, managing expectations and setting goals are the foundations for getting the patient home. Family involvement – especially for those taking a carer’s role – is particularly important. A post-discharge phone call from the rehabilitation team to follow up on how they are doing at home (Gill et al. 2014) is an ideal practice for patient-centered care.

Communication plays a large part in the care of rehabilitative patients. While communication among team members is key for collaboration, it is arguably even more important for ensuring good patient care, safety and functional outcomes for the patient. Ultimately, rehabilitation professionals all want their patients to achieve optimal function, independence and quality of life. These can best be achieved with excellent inter-professional and patient-centred communication.