Shaping Communities that Care for Frail Elders

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Despite surveys that indicate our overwhelming preference to grow old and die in our own home, those among us who grow old and frail are more likely to live in many different settings. The likelihood that we will face old age encumbered by multiple complex health conditions makes it very likely that we will, at one time or another, need care provided by an array of long-term care services and supports. If we hope to stay at home—or, at least, stay in the community—we will need services that support some degree of independence, and help up to fashion security for our finances, as well as our food, transportation, housing, and more. We will need health care, to be sure, but we will need much more—and much more than we needed during the phase of life when we were simply independent adults.

In the aging services world, the goal has long been to provide care in the least restrictive possible environment. With this aim in mind, aging services rely on community-based services which provide an array of services (e.g., not nursing homes and hospitals) that help maintain a person in their own home. These other services are rich and diverse, and include community-based group living arrangements, such as congregate housing; adult foster care residential and assisted living facilities; and community settings, such as adult day care and adult day health.

Community services include:

• care coordination/case management
• personal care assistant and attendant services
• homemaker and personal care agency services
• home hospice
• home-delivered meals
• home reconfiguration or renovation
• medication management
• skilled nursing
• telephone reassurance and monitoring services
• technologies that promote connectivity, monitoring, and telecare
• emergency help lines
• equipment rental and exchange
• transportation.

Community services often include educational and supportive group services for individuals to encourage self-care management, as well as their informal caregivers. In fact, caregiver education is positively associated with the care recipients health and quality of life.

Community services provide respite care to spell family caregivers. Friend and family caregivers are considered part of the focus for MediCaring services, and their involvement is a critical element of MediCaring, which is premised on targeting frail elders who have functional impairment to meet their specific needs.

MediCaring would center on a comprehensive care plan, which would be developed in concert with elders and their caregivers and the MediCaring team.

Today, many community services are in a state of flux; it is not entirely clear how patterns will emerge as Affordable Care Act (ACA) incentives and programs are implemented. However that plays out, there is a growing body of literature that indicates that frail elders at risk of institutionalization can successfully be served in the community. To this end, MediCaring promotes co-location of multiple services under one management unit to help harmonize needed services.

In the near future, we are likely to have computer applications that allow broad and rapid communication about available services to those involved in care planning. In such a system, a MediCaring team could see any number of factors that influence care decisions: the currently available rooms, services, consumer reviews, quality metrics, bus stops nearby, specialist nurse or physician availability, pharmacy response time, and dozens of additional elements in deciding the best and safest place for a person to live.

Any member of the MediCaring team could use the care plan as the basis for coordinating what frail elders and their caregivers need. Services would be flexible in design and delivery: if a team member noticed that outdated pills were causing delirium in a MediCaring member, that team member would be able to contact the appropriate clinician immediately to change course.

MediCaring follows the goals of enrolled elders and their families to help improve, modify, and maintain the optimum level of functioning for each. MediCaring communities will assess their regional resources and demands, while also providing an array of supportive and caring services, assuring continuity of care and following the comprehensive care plan.

key words: medicaring book, joanne lynn, janice lynch schuster, community-based services, frail elders

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