4.4 How will a MediCaring service delivery model integrate LTSS and medical services for frail elderly individuals?

The keys to effective integration of LTSS and medical care to achieve trustworthy, comprehensive services lie in the care team and the care plan (see Chapter 2). The care team must function with respect for the skills and commitment of the team members, which will generally require some training for and attention to teamwork. In the recent initiatives to improve care transitions, observers of the initial efforts at teamwork often noted that the hospital clinicians were powerful, assertive, well funded, and sometimes even arrogant, and community-based service providers were so dependent upon hospital referrals that teamwork across institutional boundaries was not possible until some baseline trust, respect, and honesty developed. Of course, the elderly patient and family were usually left out of the care team. Hospitalization of a frail elderly person ordinarily represents the “failure mode” in the chronic care plan. While hospitalization for swift, substantial, and unexpected changes in condition is important, the day-to-day support, prevention, and enablement that are at the heart of a solid, forward-looking care plan should serve to organize timely, appropriate services nearly all of the time. A MediCaring approach to care plan development would enhance the functionality of the team, in part by levelling the power relationships between health care providers and those providing social and supportive services. MediCaring Communities would enable shifting substantial focus and some revenues to where they are needed most.

Sometimes, urgent issues created by crises of housing, nutrition, transportation or family caregiving arise. MediCaring Communities will work with the existing aging network to focus on preventing such crises whenever possible and meeting them effectively when they still occur. Direct care workers can be on standby to cover a caregiver crisis; safe housing can be readily available for emergency placement; short-term funding could meet heat or air conditioning needs; and reliable and safe transportation can be available for necessary appointments and other responses. Planning ahead to address the social determinants of health, to prevent calamities when possible, and to mitigate the effects of the remaining health crises can greatly reduce the challenges they pose.

In the near future, wider use of computer applications that allow shared, rapid communication about available services to those involved in care planning will decrease the challenges of establishing and continually re-establishing criteria for eligibility, wait-lists, quality, and availability. For example, a care team will be able to see various factors that influence care decisions: the currently available rooms, services, consumer reviews, quality metrics, bus stops nearby, specialist nurse or physician availability, pharmacy response time, and dozens of additional elements that are important in deciding the best place for a person to live, temporarily or long-term. Furthermore, as Health Information Exchanges come to maturity, they will start including social and supportive services information. Then, the personal record will include not only diagnoses, medications, test results, and other medical information, but also the fact that the person relies on Meals on Wheels or is awaiting installation of a ramp to be able to get outside on her own.

For many of the practices MediCaring programs will be using, clinical measures and standards are not well settled. The initial care teams will need to have access to literature review, expert consultation, networking with other communities, and reporting of insights and data. From this work will come new standards and metrics and new wisdom in handbooks, toolkits, and textbooks. This process may well require a dozen years to be mature, but early gains will be striking.