Complex systems cannot function optimally without active monitoring of performance and management toward ongoing improvement, and someone needs to do that work. At present, individual provider and payer organizations manage their medical services under regulation and financing incentives set mostly by state and federal agencies and legislatures. Funding and regulation for LTSS, in contrast, involves the Older Americans Act and the ACL, state and local revenues and agencies, charities, and frail elders and their families (see Chapter 4). A remarkable array of providers is involved in LTSS, including private persons, large organizations, providers in niche services, and providers with broad scopes. Some are also insurers or service brokers. No one at any level is positioned to see how the overall elder care system functions and to detect oversupply, undersupply, and quality problems, and no one even has the responsibility to try to do this.
The issue of management and control will sometimes be contentious and challenging, and there is much to learn in the first few dozen communities willing to pilot the MediCaring Communities approach. We expect these pioneers to implement rather diverse strategies, reflecting the resources and opportunities that their community’s history and leadership bring to bear. For present purposes, we are using the term “Community Board” for all of the specific strategies that generate a community’s voice to decide evidence-informed priorities for improving elder care in a MediCaring Community.