The Community Board idea is novel for medical care but builds on an array of governance structures that already serve communities: school boards, neighborhood advisory commissions, and so on. In some communities, an existing medical services provider, such as the county hospital or the only medical care provider in the area is what the community turns to as the organization to remodel and mature into taking on this work. In other settings, a particularly effective Area Agency on Aging, a coalition of providers, or a public-spirited healthcare insurer could take the first steps. PACE programs already have Community Advisory Committees which could broaden and mature to serve this purpose. With the advantage of having established both trustworthiness and administrative procedures, they could invite others to join in a distinct endeavor, with arrangements that do not advantage the initial sponsor. In other communities, the local government or its public health office would be the logical initiator, having the trust, authority, and access to resources to get the work underway. Whoever takes on the organizing will need strong partners in the various provider sectors, as well as the commitment and skill to bring in representatives of the frail elders and their families. We have worked with communities where a very motivated group of citizens are willing to help establish one of these arrangements, even where the government and the providers had little inclination to notice the need before public pressure riveted their attention.
The first dozen pioneering communities willing to implement the MediCaring Communities concept will need to develop a roadmap that can guide success for later communities. Some theoretical touchstones derive from Elinor Ostrom’s insights as to how communities can organize to protect “the commons,” or their shared stake in a limited resource. Ostrom’s “design principles” of how communities can manage a shared pool of limited resources, as adapted for health care, include having clearly defined boundaries for the distribution of shared resources, having principles by which decisions are made, engaging most affected parties in the decision-making, monitoring the process and outcomes, and having the process be recognized and encouraged by state and federal authorities. These principles can help guide construction of social arrangements that enable communities to manage partial funding of gaps and to remedy quality problems. The fundamental concept is to build a self-organized and sustained governance in which all parties are allegiant to the well-being of frail elders.
In most communities, the startup of MediCaring will be smoother and more effective if it builds on a trusted and public-spirited group and has strong initial commitments from key medical and social provider stakeholders. The MediCaring Community can grow out of a provider coalition or a citizens’ activist group, but it must become a legal entity, on its own or as part of local government or an existing non-profit provider organization, in order to have authority and to be able to manage data and funds responsibly.
 (Ostrom 1990)