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Key concepts taught

Partnership in care/services



Since fall 2013, the partnership of care and services model developed by Réseau universitaire intégré de santé de l'UdeM (RUISUM) is taught in CSS courses. The adaptation of this model is based on the National Interprofessional Competency Framework (www.cihc.ca) (2010) and The CanMEDS Physician Competency Framework 2005.


Partnership in care service

Source: Réseau universitaire intégré de santé de l'UdeM (RUISUM)


Adaptated from :


Canadian Interprofessional Health Collaborative (2010). A National Interprofessional Competency Framework. 32 p. [Online] URL: http://www.cihc.ca (Accessed on 13-05-16)


Royal College of Physicians and Surgeons of Canada (2005). The CanMEDS Physician Competency Framework 2005. [Online] URL :    http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework (Accessed on 13-05-16)



Partnership evolution

Source: Direction collaboration et partenariat patient (DCPP)


Partnership in care

Source: Direction collaboration et partenariat patient (DCPP)



Interprofessional collaboration



According to the Canadian Interprofessional Health Collaborative, interprofessional collaboration is defined as being “the process of developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes. 


During the CSS courses, the students are taught the National Interprofessional Competency Framework for Healthcare.


National Competency Framework

Source: www.cihc.ca



The Patient as partner



The Collaboration and patient partnership unit describes the "patient as partner" as follows:

  • The patient partner is a person who is gradually enabled to make free and enlightened health care choices.
  • He is respected in all aspects of his being and he is a full member of his interprofessional team.
  • His ‘life-project’ constitutes the guiding principle according to which clinical decisions are to be made. 


The following diagram illustrates the patient-partner's frame of reference:


Patient partnership
































Source: Direction collaboration et partenariat patient (DCPP)



Life plan


The concept of a life plan is taught, as defined by Ibarra Arana: [TRANSLATION] "The life plan is a mental representation of the life that the patient wants to lead and the ways and means that he adopts in order to succeed. He influences the direction of his own behaviour through time and circumstances. He takes part in the search for the direction and the motivation for the decisions to be made as well as the meaning to be given to the course of his life (his 'life course')."


(IBARRA ARANA, Claudia Elena, (under the guidance of) Michaël Reicherts. L'élaboration du projet de vie chez les jeunes adultes, Université de Fribourg, Switzerland, 2006, 280 p.)



Interdisciplinary Intervention Plan (IIP)


The Interdisciplinary Intervention Plan is developed by the clinical team. This tool supports the integration of the clinical team's interventions. It contains all the physical, psychological, social and spiritual measures, if applicable, prioritized by the team, including the patient and his family or their representative. The IIP consists of the following aspects:  

  • a list of the important problems and the essential information needed to understand the problems the patient is facing
  • the overall goals  and specific objectives to be attained to realize the patient's life plan
  • prioritize interventions to address each  targeted problem and  indicate which practitioner is responsible for meeting the objective, with the participation and consent of the patient and their family or their representative
  • development of a follow-up plan to meet the objectives set out and establish timelines to review the plan

(Adapted from: Lebel P, Massé-Thibaudeau G. Programme de formation à l'interdisciplinaritéCahier de formation pour les formateurs. Montréal: Institut universitaire de gériatrie de Montréal; 1999)