Individualised Care and Rehabilitation

Abstract

In this chapter individualised rehabilitation is referring to the process of returning to, or maintaining, a meaningful everyday life, valued activities and roles in the context of an illness or a health condition. Rehabilitation usually involves at least two perspectives, i.e. that of the individual person who has a health condition or an illness and that of the enablers, e.g. health service workers. In individualised rehabilitation, the medical diagnosis itself is not enough for the understanding of the individual person’s situation nor for his/her needs of rehabilitation. Instead, a wider framework is useful such as the biopsychosocial model in which the state of health is seen as an interaction between biological, psychological, and social factors as outlined in WHO’s International Classification of Functioning, Disability and Health (ICF). Health can be promoted by creating environments where people in need of rehabilitation are active participating actors, who are supported to identify their internal and external resources and learn how to use and reuse them to reach vital goals in their everyday lives. Individualised rehabilitation entails a problem-solving process of interrelated phases performed by the individual in partnership with health professionals in a rehabilitation team. The process entails to establish a shared understanding; identify, negotiate and agree on short-term and long-term goals; together plan interventions required to reach the goals; put the plan into action; and evaluate and reflect on goal attainment.