As we continue the conversation on what Community Catalyst believes are the key areas advocates should focus in health system transformation, up next on our list is: creating a person-centered culture of care.

The health system can be a challenge for anyone to navigate, particularly for those with frailties, multiple chronic conditions or complex disabilities. On average, Medicare beneficiaries with multiple chronic conditions have 13 or more physician visits, are more likely to visit the emergency room, and fill 49 prescriptions per year. Keeping track of doctors’ visits, medication changes, and provider recommendations is no simple task, making it easy for something to fall through the cracks. Health care providers must work as a team, with the patient at the center, in order to achieve safer and more effective care that is in line with patients’ goals, values and preferences.

A simple concept, and yet in practice it can be challenging to implement. For example, findings from a new survey conducted in collaboration with the Association for Community-Affiliated Plans revealed that many of the health plans serving Medicare/Medicaid beneficiaries under the Financial Alignment Initiative found it challenging to engage Primary Care Providers in the care team and found operational issues in the system, such as implementing an effective IT system that enables communication among care team members, as a barrier to coordinating care for their members. These findings were reinforced by a recent survey of beneficiaries enrolled in MyCare Ohio, the state’s dual eligible demonstration project. The survey uncovered many holes in the demonstration plans’ care coordination models, including that many consumers are not part of their own care planning process or that their care team did not include people they wanted.

To make care better and safer for patients, person-centered care has to be at the heart of what we do.

In order to improve care and reduce costs, health care providers, plans and policymakers must work toward the integration of physical and behavioral health services with community supports and services. The experience of health care organizations serving some of the most complex populations (patients who are dually eligible for Medicare and Medicaid), has helped identify core components for this kind of person-centered care:

  • Timely, Comprehensive Health Risk Assessments
    • Assessments should include functional status information, cultural and linguistic preferences and information about caregiver roles in order to create an individualized plan of care. 
  • Incorporation of a Patient Preferences into the Plan of Care
    • A care plan must be developed in accordance with the patient’s values, goals and preferences, and with the patient at the center of the conversation. Care shaped by patient’s goals and preferences is important at every point in the care continuum but is particularly critical in palliative and end-of-life care.
  • Seamless Care Transitions
    • Transitions should be safe, seamless, and person-centered across care settings. When preparing for discharge from the hospital, for example, the patient must be central to the planning process. Instructions must be clear and understandable to the patient and family caregiver (where applicable). The discharge plan must be communicated to other members of the patient’s care team, and appropriate post-discharge care should be arranged for the patient.
  • Culturally Competent Care Teams
    • The care team should include diverse providers that understand the needs and preferences of the person being served. Aside from clinical providers, team members could include long-term service and supports providers, peer recovery counselors and/or community health workers.

We believe that these are just some of the key elements of achieving a person-centered culture of care, especially for three vulnerable populations: dual Medicare/Medicaid beneficiaries, people with substance use disorders and children and youth with special health care needs. Other considerations include building a strong payment structure that supports these elements, meaningful consumer engagement in the design, implementation, and evaluation of programs, and patient engagement in clinical decision making and care.

We know that putting these pieces of the puzzle together is not going to happen overnight, but there is a better way to better health, and consumers and their advocates have a critical role in pushing for structural changes that will get us there. We look forward to working with you on these important issues as we kick off our new Center for Consumer Engagement in Health Innovation.