In the first pilots, only communities with some advantages should implement MediCaring Communities models. The endeavor will have challenges and risks that care patterns will drift back to current dysfunctions. Successful implementation will require a great deal of attention, collaboration, and trust on the part of leaders in the communities, and those are easily disrupted. Therefore, we should start with communities that seem more likely than most to succeed.
What characteristics are likely to predict success?
- First, the community should have a tradition of cooperation in the public interest: e.g., generating standardized forms for information transfer at hospital discharge, working together for child health or other social challenges, or raising money for community projects. Communities with factions that dislike or distrust one another would seem to have undue challenges in building the Community Board, referring likely elders to PACE, or supporting the priorities for reinvestment of savings.
- Second, the community should have reasonably natural boundaries, so nearly all people already know if they are part of that community or not. The boundaries can be features of the natural topography, or geo-political boundaries, or long-standing loyalties; but having the market areas of providers match up with the population of concern and the political divisions helps align public investments with private activities. Having most of the medical services provided in the defined community by providers located in that community creates the opportunity for a relatively closed system that does not lose opportunities as does a larger or more overlapping marketplace. In a community where 90% of services to frail elders in the community are provided within the community, the reforms fuel savings that enable community investments. In a community where only 45% of services to that community’s frail elders are within that community, the effectiveness of reforms will be attenuated when the elder is getting services outside the community, and savings will be limited by the behaviors of people who are not invested in the community’s success.
- Third, the community needs to have leaders willing to put their shoulders to the wheel, willing to encounter some adversity, and willing to pursue the vision of good elder care at a sustainable cost despite not knowing all the hazards and challenges along the way. Those leaders can be laypersons, politicians, clinicians, business executives, or anyone else in a position of influence, and ideally the group of leaders willing to undertake the journey will have come from various backgrounds.
We are finding many communities that would be good candidates. Some have citizens’ groups that have seen how elderly people are living in their communities now and they see the degradation of even that inadequate level of support as the numbers rise. Some face remarkable short-term increases in the numbers and proportion of frail elders, due to historical and current migration patterns for work and retirement. Some have a health plan or provider with leadership that is fed up with the routine of mismanagement of the issues facing frail elders, often because of experience with a loved one. Professional pride demands that they take steps to improve performance. PACE programs already have a geographic scope and have learned to work with their community’s other providers and their civic leaders. So, existing PACE programs in communities with attractive features can take on the initial pilots.