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Our mutual work is centred on functional partnerships and systems where the individual’s goals and needs are uppermost in our planning. A strong partnership must be developed between the care service providers and the individual’s care system network.
Our partners consist of the following:
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Family members |
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Caregivers |
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Community resources |
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Ministry of Health and other serving systems |
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Other members of the individual’s community |
Facilitating partnership
It is important to strive for communication and collaboration that is inclusive of all community players and the PAC. Sharing of information is client centred and admission goals are balanced with realistic and attainable strategies. An interim meeting reviews planning and shares client progress with community players.
Community outreach involves a personal connection with community players and clients prior to and after admission. The PAC community outreach supervisor provides a range of outreach and consultative services to all PAC partners, support systems, families, caregivers, and community professionals.
At discharge, summary reports based on PAC’s clinical assessment, including recommendations, are provided to the individual’s community care team.
For success, the following principles are key:
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Continuity of care |
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Pro-individual planning |
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Ongoing communication and collaboration between all involved: the PAC, families, community mental health teams, and other partners |
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Follow-up care and commitment to life-long planning and review |
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