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This infographic highlights the critical role of health literacy in reducing 30-day hospital readmissions among older adults. It presents statistics on low health literacy in Canada, outlines contributing factors, and introduces an evidence-based intervention using simplified discharge summaries, teach-back education, and follow-up calls. Guided by the Interactive Systems Framework (ISF), the initiative emphasizes staff training, leadership support, and collaboration to strengthen patient understanding, safety, and continuity of care. Please right click to view in new tab

04 November 18, 2025

Community Engagement: A Case Study that Explores the Importance of a Patient and Family Advisory Council

See below for a full case study that brings to life the  engagement process of introducing a PFAC, to a facility. The chart version, can be found on my blog post page!

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Organization

Transitional Care Unit PFAC Council

URL Patient and Family Advisory Council | KHSC Kingston Health Sciences Centre

Areas of Focus

• Transitional care for medically stable but functionally vulnerable adults (often older adults) who are not yet ready to return home or waiting for long-term care.

• Safe, person- and family-centered transitions from acute care to TCU, and from TCU to home, long-term care, or other community settings.

• Supporting during the transition phase on the acceptance of Long Term Care

• Improving patient, family, and caregiver experience, communication, and trust in the TCU environment.

• Embedding patient and family voice in quality improvement, policy, and operational decisions at the TCU. 

Relevant to Social Determinants of Health and Health Equity

• Age and functional status (frailty, mobility limitations, high care needs).

• Income and housing security (ability to return safely home, afford supports, or secure appropriate LTC placement).

• Social support and caregiver capacity (family burnout, distance, and availability).

• Geography (rural/remote communities who must travel for visits and follow-up).

• Health literacy and language barriers, especially in complex discharge or placement decisions.

Intended Use

• Bring former and current TCU patients and family caregivers into ongoing dialogue with hospital leaders, TCU staff, and partner organizations.

• Inform policies, workflows, communication tools, and environmental changes at the TCU based on lived experience.

• Identify barriers to safe, person-centered transitions and co-design solutions (e.g., admission information, bedside communication tools, discharge planning supports).

• Build trust and transparency between the TCU, families, and hospital partners, particularly following periods of heightened complaints or concerns.

Principles/ Values

• Respect and dignity: Recognizing patients and families as experts in their own experience.

• Equity and inclusion:  Intentionally seeking participation from those most impacted by TCU care (e.g., caregivers of frail older adults, transitioning to LTC)

• Partnership and co-creation: Working with families to co-designing processes and solutions alongside them.

• Transparency and accountability: Closing the feedback loop by showing what was heard and what is being changed as a result.

• Cultural safety and humility: Being attentive to Indigenous, newcomer, and other marginalized communities’ experiences in institutional care.

• Continuous learning: Using feedback and evaluation to refine PFAC activities and TCU improvements over time.

Tools/ Guides

• Terms of reference outlining membership, roles, decision-making, and expectations of meetings

• Recruitment materials (posters, admission packages) to identify interested former patients and family caregivers.

• Issue/theme trackers to organize feedback into categories (e.g., communication, environment, safety, discharge planning, staff interactions).

• Draft and revised patient/family information tools, such as:

  • Admission welcome/what-to-expect sheets

  • Discharge planning checklists

  • Contact information/reference sheets

• Complaint/concern metrics from patient relations used as inputs for PFAC conversation and co-design work.

Strategies

• PFAC meetings centering lived experience and storytelling.

• Co-design of admission, communication, and discharge materials.

• Feedback-driven revisions to processes (e.g., expectations on admission, bedside communication).

• Walkaround observations) guided by PFAC insights.

• Look for themes in patient/family feedback (complaints, compliments, surveys).

• Completing the feedback loop with concluding evaluations

• Integration of PFAC themes into quality improvement and accreditation reports.

• Care-planning discussions informed by PFAC-identified needs.

Barriers/ Risks

• Power imbalances and fear of speaking honestly in a hospital-led forum.

• Emotional strain for families revisiting difficult TCU experiences.

• Limited representation of diverse caregivers (rural, cultural, linguistic).

• Time constraints for both families and staff.

• Historical mistrust due to previous concerns or complaints.

• Staff turnover or inconsistent leadership engagement. 

• Patient turn over due to the temporary transitional care phase

Success Factors

• Visible, concrete changes resulting from PFAC input

• Strong leadership commitment and consistent attendance.

• Safe, inclusive meeting environment that elevates quieter voices.

• Diversity of PFAC membership reflecting TCU patient population.

• Integration of PFAC insights into QI, SOPs, audits, and accreditation.

• Stable support structures like the recognition of advisors

Evaluation

• Number and diversity of PFAC members.

• Consistency and frequency of meetings.

• Volume and themes of issues raised.

• Implementation of PFAC-informed changes.

• Trends in patient/family experience, complaints, and compliments.

• PFAC member perception of influence and respect.

• Evidence of PFAC impact on policy, QI, or accreditation work.

Other Comments

• The TCU PFAC lines up with WHO’s idea of community engagement as an ongoing relationship, not a one-time consultation. Right now, it mostly sits at the “involve/collaborate” level, with the hope that over time patients and families will take on an even bigger role in shaping how the TCU runs (WHO, 2020)

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National Collaborating Centre for Determinants of Health. (2013). A guide to community engagement frameworks for action on the social determinants of health and health equity. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University. http://nccdh.ca/images/uploads/Community_Engagement_EN_web.pdf 

World Health Organization. (2020). Community engagement: a health promotion guide for universal health coverage in the hands of the people. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789240010529