Implementation of Person-Centered Care Model
Entity which complete it
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Stating Year
Where it takes place
Range of age
Type of disability
Project link
Why is it a good practice of the Person-Centered Model?
Transformation process of the foundation’s residential centers towards a Person-Centered Care Model (PCC), with the aim of ensuring that the decisions, preferences and values of each person are the basis of their life project and the support they receive. The model has been applied in the different facilities of the entity through the creation of meaningful, flexible and personalized environments.
Person-centered approach: Residents actively participate in decision-making about their daily lives, supports are designed individually and coexistence centered on relationships, bonds and sense of belonging is promoted. Staff receives specific training to implement this approach in daily support.
Integrated Assessment (Person, Family, Housing) and Life History
The foundation’s approach is rooted in a holistic understanding of each person’s situation. An integrated assessment would naturally include their clinical needs, personal history, family and social environment, and the conditions of their home or residence. The organisation’s long trajectory in mental health, neurorehabilitation, intellectual disability and elder care suggests a model that looks beyond symptoms and diagnoses, paying attention to the person’s life narrative, support networks and living context. This broad perspective helps shape interventions that respect individual dignity and promote wellbeing.
Personalised Care and Support Plan for the Life Project
From this comprehensive view, personalised care plans are designed to align with each person’s goals, capabilities and aspirations. Whether the support focuses on rehabilitation, daily living, social participation or long-term residential care, the emphasis is on tailoring interventions to the individual. Plans evolve over time, adjusting to progress, changes in health or shifts in the person’s life direction. The intention is not only to provide care but to accompany each person in sustaining or rebuilding a meaningful life project, promoting autonomy to the greatest extent possible.
Support groups
Although the organisation offers extensive professional services, opportunities remain to strengthen peer and family support structures. Support groups could offer emotional connection, shared learning and community involvement, complementing the formal services provided by professionals. Such groups—whether for users, families or caregivers—would help create a sense of belonging and mutual understanding, reinforcing the therapeutic and rehabilitative work carried out by the foundation.
Case Management and Resource Coordinator
Given the complexity of the populations served, effective case management is essential. A coordinated approach ensures continuity between clinical treatment, rehabilitation, residential support, social resources and community reintegration. Case managers or resource coordinators would follow each person’s journey, help navigate services, anticipate needs and respond to changes. This integrated oversight strengthens the quality, coherence and person-centred nature of the support provided.
Highlined results
Improvement in the quality of life of residents, greater involvement of professional teams and progress in the deinstitutionalization of practices and spaces. The process has served as a reference for other centers in the Basque environment.
Inspiring ideas for other enviorments. It can works! 😉
The foundation demonstrates how a long-standing organisation can integrate healthcare, rehabilitation and social support into a unified model grounded in dignity and hospitality. Its multidisciplinary structure shows that it is possible to offer continuity of care across different life phases and levels of dependency, while maintaining a person-centred ethos. This model—combining clinical expertise, rehabilitation, community inclusion and ethical values—can inspire similar initiatives elsewhere, especially those seeking to blend tradition with innovation.
Other observations
Ospitalarioak Fundazioa