Academic journal article Generations

Bringing the Pieces Together: Person-Centeredness Is Key to Transforming Policy and Services

Academic journal article Generations

Bringing the Pieces Together: Person-Centeredness Is Key to Transforming Policy and Services

Article excerpt

policy makers, providers, and consumer advocates have struggled for years with two seemingly disparate yet interrelated phenomena that affect access, quality, and health services cost in the United States. The first phenomenon is that the United States spends much more on healthcare and much less on non-medical supportive services than any other industrialized nation, with overall abysmal results ensuing for quality of health and life measures (Squires and Anderson, 2015).

This discrepancy affects all people who encounter the healthcare system, including older adults who currently are healthy and want to stay that way. Yet its negative impact is most pronounced among the small percentage of older adults living with multiple chronic health conditions and functional limitations-individuals who have nearly doubled the Medicare spending of their healthier counterparts and experience few improvements on quality (Komisar and Feder, 2011; Rodriguez et al., 2014).

The second phenomenon is that services for older adults, particularly for people with significant health and daily living needs, are fragmented, uncoordinated, unresponsive, and difficult to access for these individuals and their family caregivers (Commission on Long-Term Care, 2013; Stone, 2000). Most older adults, regardless of their level of need, can and do live at home in their community-and have a better chance of staying at home if they have support from family and friends, and access to safe and affordable housing, reliable transportation, responsive medical care, and other needed services. However each service line-healthcare in its various forms, behavioral health, rehabilitation, long-term services and supports (LTSS), community-living supports, caregiver services, and housing, to name severaloperates as its own unit with separate policy structures, funding, and measurement criteria that define success or failure.

At the system level, these intersecting phenomena result in isolated programs, operated by an overwhelmed workforce through unbalanced and rigid financing, all trying to meet a burgeoning need. At the person level, the results are similarly untenable: individuals (particularly older adults) in need and their family caregivers feel engulfed by an information overload in a nonsensical service maze, while simultaneously feeling abandoned by providers that adhere only to their own program rules and boundaries.

A solution to this conundrum is twofold: reorient the management philosophy and operations of delivery systems to a person-centered care framework; and foster connections across services platforms toward care integration that rewards value and person-focused outcomes. This article discusses elements contributing to the state of high-cost-low-value institutional structures, current efforts to better integrate services through a person-centered care framework, and policy directions for the future.

How Did We Get High-Cost-Low-Value Institutional Structures?

While most system thinkers assert the truism in the famous quote that states "every system is perfectly designed to get the results it gets" (Batalden and Conway, 2015), most might also agree that poorly performing systems, from the end-user perspective, were not designed with such failure in mind. Rather, systems evolve in response to internal and external forces (e.g., demographic, economic, policy, and political) over time, and are driven by expectations of their worth and value, or lack thereof (Pressman and Wildavsky, 1984).

This holds true for systems serving older adults. Few people developing the first laws, regulations, and financing for nursing facilities could have anticipated how population aging, advances in healthcare and rehabilitative sciences, state politics, federal funding, and the Affordable Care Act would transform the industry from almshouses to what is primarily a post-acute-care service line. Even fewer could have imagined the interplay between hospitals and nursing facilities that often occurs when a seriously ill person has psychosocial and environmental challenges neither entity can solve, resulting in a hospitalto-facility-to-hospital discharge loop that ends only when outside forces, such as family members or death, intervene. …

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