5.2 What capabilities and authorities does the Community Board need to have?

The list of desirable characteristics for a Community Board has been given above. What advice can we give to leaders in communities that aim to establish such a Board? First, organizers will need to consider carefully how to designate their “community.” Having well-established boundaries and a clear understanding of how local issues are generally handled will be an advantage. People are more willing to work for the well-being of their own “hometown” than for a set of poorly aligned ZIP codes. In addition, many services are already organized around established geo-political boundaries. This argues for generally using cities and counties. Especially in the initial stages, having a strong community spirit and a tradition of shared governance and community loyalty will help.

The size of the enterprise deserves attention. Generally, very small populations will not have the array of needed services nor the revenues to support monitoring and governance, and very large and populous areas will have too many contentious forces to allow governance to get underway, but both generalizations will have exceptions.

Except for the unusual situation in which a geographic area functions as an island with the health care market area nearly congruent with the geo-political boundaries, there will be mismatches of the boundaries of “community” with the indistinct service area of various service providers in that community. For example, a community with three hospitals might well have at least one that has a substantial proportion of patients from outside the home community. The decision could be to expand the community to include some contiguous areas or to measure quality within the established community but continue to provide services to others. The solution adopted will depend upon local factors, including leadership, funding, and a concern to avoid orphaning nearby areas with sparse populations.

An effort to create excellence in one jurisdiction will attract potential participants from nearby areas. Each community will need to consider how to deal with frail elders who want to join their MediCaring effort but who live outside the covered area. Some MediCaring Communities may, at least at first and when tied to local funding or chartering, simply restrict their geographic scope so they can maximize the effectiveness of their monitoring and system management.

How can the Community Board be vested with appropriate authority? Here are some possibilities. The local government can charter the Board, grant it certain authorities, provide seed funding, require testimony on the adequacy of current service capacity before various arms of government (city councils, zoning boards, etc.). The initial charter can require that the Board have control over reinvestment of some of the MediCaring Community’s Medicare savings and that it produce periodic reports as to the progress made in achieving important service improvements for frail elders.

Importantly, the Community Board could be developed by an Area Agency on Aging or a PACE program as a broadening of their existing community advisory board. Government, philanthropy, or their sponsor could provide operational funding and the data needed for monitoring. The Board needs to have an independent voice, so that it can speak out and claim sufficient authority to represent the interests of frail elders, work with the public, and make their insights and decisions very difficult to ignore.

The Community Board needs to represent the interests of frail elders and their family caregivers first and foremost; but it also should attend to the interests of providers, including personal and home care aides. The Board also has to be established in a way that engages and involves locally powerful entities in the community, all while ensuring fairness and openness. The actions of the Board, and the data on which they rely, must be public. At the same time, the identities of individual elderly persons must be kept private unless publicized with knowledgeable consent. This consideration may sometimes make it improper to put data or decisions in public that arose from unusual and identifiable situations. With this exception, the overall patterns of supply and quality and the costs of services require openness to the public. The public should be well informed and should see the process as being trustworthy and valuable. The requirement for openness, along with the pressure to meet more needs, will make it very unlikely that an investor-owned company could operate a MediCaring Community and support its Board, unless they invested through a carefully designed payment plan that limited their return on investment.