Rehabilitation is the primary care strategy of the Department of the Elderly and Disabled in the City of Odense.
The care to citizen - the elderly, the disabled and the citizens with physical and mental disabilities – is based on the life situation of the citizen. This involves a holistic perspective and collaboration on every aspect both physical, mental and social depending on the resources, wishes and needs of the citizen.
The planning of the interventions and the collaboration with the care professionals is based on the citizen’s goals. The citizen’s experience of the impact of the interventions is then measured and monitored.
At the conference, New Nordic Welfare 2017, an overview of how the rehabilitation strategy is implemented and the organizational, professional and technical aspects of the implementation will be presented (NB in Danish).
Examples will illustrate how a goal-based collaboration impacted the citizens. One of these is how the professional tools - motivational Interviewing (MI) - have supported the collaboration based on the goals of the citizen, and how technical solutions supports interdisciplinary collaboration, workflow and information sharing.
One and same care record for all professionals have made it possible to use real-time data for decision-making both related to the individual citizen and for a group of citizens. That involves information on performance, services delivered, and goal achievement for the citizen’s targets.
The Department of the Elderly and Disabled in the City of Odense has implemented performance and data-driven management with databased information and dialogue meeting.
The information about the impact can be used for dialogue, learning and quality improvement of the rehabilitation strategy of the department. The focus on impact to citizens align the efforts of all parts of the organization including the director’s strategical focus, the manager’s tactical focus. This will influence the operational focus of the employees when working together with the citizen on achieving goals and monitoring the impact of the interventions.
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