Family centered care

Assistant Editor-In-Chief: Michelle Lew

Overview
Family-centered Care is a method of medical intervention that shapes health care policies, programs, facility design, and day-to-day interactions among patients, families, physicians, nurses, and other health care professionals by making a patient's family an integral and co-equal part of a healthcare team. A patient, and their family's, experience with their care is widely recognized as an essential part of health care outcomes. Thus, under family centered care, the patient's family supports the patient while he/she is in the hospital, and the family members are generally closely involved with the care and care plan of the patient.

Making patients and their families integral and coequal parts of the health care team improve the quality and safety of a patient's care by helping to foster communication between them and health care professionals; by taking familial/patient input and concerns into account, the patient and family feels comfortable questioning staff on a patient's plan of care, and both patients and their families are "on board" in terms of what to expect with medical interventions and health outcomes. Family centered approaches to health care intervention also generally lead to wiser allocation of health care resources, as well as greater patient and family satisfaction.

Family
Medical facilities that implement family-centered care generally define "family" as a patient's spouse, significant other, parent, adult children, friends, or other primary caregivers as identified by the patients themselves, or a legal surrogate. Strides are made to be as inclusive as possible with this process; however, not all medical facilities will grant access to domestic partners in cases where doing so conflicts with local law (such as the HIPPA in the United States). However, recently these definitions have been changed to instead reflect the wishes of the patient, and health care facilities will generally only bar someone from the process if asked to do so by the patient, a legal surrogate if the patient is incapacitated, or if required by law.

Role of the Family
While specific methods of implementing family-centered care differ from facility to facility, general procedures are fairly similar. The University of Virginia Health System in Charlottesville, Virginia, provides an excellent example of this. On admission, the patient usually designates one or two people who will serve as their primary "care partners." These individuals are notated in the patient's electronic and physical medical charts, and they are given an orange wristband to wear in order to designate them as a patient's "care partners." This negates the need for visitor's passes or after-hours registration cards, as the staff can readily identify a patient's "care partners." The admitting staff discuss the reasons for admission with the patient and their "care partners" and what health criteria are required for the patient's discharge.

"Care partners" are then intricately involved with the patient's care by their entire attending healthcare team, including physicians, nurses, nutritionists, social workers, and more. At every stage, "care partners" and patients discuss with healthcare professionals test results, the state of the patient's current health, what type of things to expect throughout the day, and discharge goals. "Care partners" are invited to take part in nursing interventions, including bathing, feeding, helping the nursing staff with moving the patient, and assisting the patient in exercising or moving about the unit. "Care partners" are also invited to take an active role in "rounds," providing feedback and asking questions reflective of theirs and the patient's wishes or concerns.

"Care partners" are also indoctrinated on various elements of hospital operating policy, such as quiet time and visitation rules. The "care partners" are then generally allowed to manage the adherence to these policies in a manner conducive to the patient's healing and common sense -- for example, by managing how many visitors are present in the patient's room.

Advantages and Disadvantages
Family Centered care emerged as an important concept in health care at the end of the 20th century; but the implementation of Family Centered care was met with a variety of snags. Prior to the early 1990s, the relationship between care providers and patients was distant. The traditional model of care centered around physicians, and an expectation that patients and their families would assume a passive role as an observer, rather than a participant. Healing was treated largely as an abstract or business-like affair. Special requests by the patient were seen as interfering with the provision of their care or even as being a detriment to their health. Modern ideas like open visitation or care partners were almost unheard of and were generally dismissed as impossible to accomplish. This was compounded by the implementation of Health Maintenance Organizations, which successfully reigned in the rising healthcare costs of the 1970s at the cost of the patient-healthcare worker relationship.

Much of the early work on Family Centered care emerged from the pediatric and geriatric medicine fields; for example, as research came to light about the effects of separating hospitalized children from their families, many healthcare institutions began to adopt policies that welcomed family members to be with their child around the clock. As awareness increased of the importance of meeting the psychosocial and holistic needs of not only children, but all patients, the family-centered care model began to make serious headway as a bond fide intervention model. In the United States, this was further encouraged by Federal legislation in the late 1980s and early 1990s that provided additional validation on the importance of family-centered principles.

The implementation of family-centered care was met with a variety of snags. In the early 1990s, the health care dynamic of Western medicine was dramatically different than today. Healing was treated largely as an abstract or business-like affair. Special requests by the patient were seen as interfering with the provision of their care or even as being a detriment to their health. Modern ideas like open visitation or care partners were almost unheard of and were generally dismissed as impossible to accomplish. In the United States, this was compounded by the implementation of Health Maintenance Organizations, which successfully reigned in the rising health care costs of the 1970s at the cost of the patient-health care worker relationship.

Beginning in the mid-90's (although elements of family-centered care began appearing in the early 1980s), however, this situation began to change. Studies began to show that many of the supposed detriments to family-centered care were negligible, not supported by research, or untrue. A study conducted in 2001 showed that open visitation had little to no effect on physiologic parameters such as heart rate, blood pressure, respiratory rate, cardiac arrhythmias, and intercranial pressure. Indeed, evidence suggested anxiety levels and general cardiovascular health were positively affected after the implementation of family-centered care, leading to fewer medical interventions being required (physical or chemical therapies in particular). Another area of concern, septic and infection control, found that as long as a patient's visitors were educated in the proper aseptic procedure (such as hand washing and use of hand sanitizer gel), infection control outcomes were not negatively affected by unrestricted visitation.

Patient care was also positively affected. Decubidation rates in facilities with family-centered care dropped significantly. In one study, it was found that patients receiving family-centered care were far more likely to have met the criteria of medical and nursing care plans (such as drinking x amount of fluids every eight hours, moving from NP suctioning to bulb suctioning, or the measurement of patient's intake/output), as the patient's family took it upon themselves to encourage or assist the patient in accomplishing these goals. Family and close friends were more likely to identify slight variations in the patient's mental or physical health that health care professionals largely unfamiliar with the patient may miss. Furthermore, while health care professionals are very talented at their work, their jobs are generally limited by the walls of the health care facility, whereas a patient's family is not. Enlisting a patient's family as a part of their health care team helps enable their ability to assist, manage, and assess the patient's healing after their discharge from a health care facility.

A study undertaken at the University of Virginia's Children's Hospital showed that sharing information and involving family in a patient's care (via the family-centered care model described previously) had the following effects:
 * A rise in staff satisfaction due to reduced phone calls by security at night;
 * Improved consistency of information given to family members;
 * A decrease in clinicial workload; and
 * A significant rise in patient satisfaction scores on the Press-Ganey scale in the areas of Accommodations and Comfort of Visitors (93 to 98), Information Provided to Family (87 to 99), Staff Attitudes Towards Visitors (62 to 75), and Safety and Security Felt at the Hospital (86 to 88).