An effective MediCaring Community initiative requires that an entity acting in the public interest be monitoring performance and using data to guide improvements in service delivery supply and quality and to ensure efficiency. Who should do that work, and how should they do it? Thinking about this requires stepping back to consider the possible social structures that could engender management functions such as monitoring progress, setting priorities, and implementing improvements. The entity responsible for this work should probably have the following characteristics:
- Be local or regional, so its scope comports with widely understood geo-political boundaries;
- Actively solicit input from the community as to priorities for the care of frail elders;
- Include elders and caregivers in the voting membership;
- Be of a size that is neither overwhelming nor too small to support the endeavor;
- Take responsibility for the well-being of all frail elders in the geographic area, rather than just those with particular funding or providers;
- Be transparent with data and decision-making and accountable to the public for the use of resources;
- Able to build a realistic and inspiring vision of the achievable improved care system;
- Able to build cooperation in the community interest, while respecting the role of competition;
- Monitor service supply, distribution, and quality;
- Monitor the experience of frail elders and their families and the perceptions of the public;
- Provide a forum for considering the data and a decision-making process that sets priorities for improvements;
- Identify opportunities for improvement and see that they are tested and, if successful, sustained;
- Shift attention and resources toward optimal supply, distribution, and quality through influence on law and regulations, capital investment, performance metrics, community development, finance, and workforce enhancement; and,
- Have some widely accepted authority, either by being publicly chartered, by being lodged in a governmental entity, or by representing such a strong coalition that it can act in the public interest without explicit governmental authority.
Why should this capability for monitoring and management be built at the community level? The answer is that people living with serious disabilities in old age come to be tied to their homes. They cannot readily travel even a few hours to get services. What we need at that time in our lives has to be available where we live.
If a community has a cadre of home health aides with skills in serving dementia patients with behavioral challenges, then a family that needs that help will get it. If the community has been attentive to universal design in new construction and renovations, there will be many housing units ready for disabled persons to thrive. If the community has ensured that every elder in need can get home-delivered food, then there is very little malnutrition and hunger. But if the community has not done these kinds of things, then the family and elderly person who need those services will simply be unable to obtain them. No one family can make the system work well if it is not working well for all.
This grounding in the community makes the argument for preferring a community locus for managing the system. Also, a community or its subsets can be small enough for the staff to get to know its resources and flexibilities. A person at the state level cannot know about traffic patterns in bad weather or what pharmacy will deliver after hours; but the person who lives there can know these critical details. Also, part of the workings of a MediCaring Community is to build a commitment to the common good, so that people who forego a costly treatment have the sense that doing so is not only acceptable to them but also benefits their community. People who live in that community should become proud of their shared commitment to a decent last phase of life.
These are also some of the reasons to press for MediCaring Community programs to aim to take substantial responsibility for the well-being of all frail elderly people in their geographic area. Rather than the overlapping patchwork of persons who sign up with one or another health care insurer or who happen to use one or another hospital, a MediCaring Community needs to aim for well-being of the affected persons in the whole population. It will not be enough to provide excellent care to a subset and leave many elderly neighbors facing unreliable services, abandonment, and despair. The MediCaring approach should be the “gold standard” and these services should be available to all frail elders who live in the geographic community. Just as one cannot fix the availability of housing or food for just the persons signed up in a particular health plan, one cannot claim to be responding to the needs of the frail elders in the community if the important services are available only to some of them.