How a Person-Centered Approach to Care Planning Improves Outcomes

Katherine Tardiff, MSN, RN, GNP-BC, vice president of clinical operations at Seniorlink, discussed the impact that a person-centered care planning initiative had on satisfaction outcomes in complex populations, during a session at Health Care Quality Congress.

According to the expert panel that created person-centered care:

“’Person-centered care mean that individuals’ values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires.”

Ms Tardiff then explained the elements that are essential to better understand the definition of person-centered care. She said that the individualized, goal-oriented care plan is comprised of:

• Performance measurement and quality improvement using feedback from the person and caregivers;
• Education and training for providers and, when appropriate, the person and those important to the person;
• Continual information sharing and integrated communication;
• Ongoing review of the person’s goals and care plan;
• Care supported by an inter-professionals team in which the person is an integral team member;
• One primary or lead point of contact on the health care team; and,
• Active coordination among all health care and supportive service providers.

Ms Tardiff noted that there is a growing demand for person-centered care. She said that in 2000, the population requiring long-term care (LTC) services was roughly 15 million and it is expected that by 2050, 27 million patients will require those services. She also explained that the impact of family caregiver involvement results in 30% fewer ER visits and 50% lower hospital utilization.

“Caregivers provide over $500 billion in unpaid care to loved ones,” Ms Tardiff said.

She continued to explain that the home is the lowest cost setting for care. According to Ms Tardiff, “there are 14 million hospital discharges annually of which nearly half are sent to the lowest cost health setting—the home.”

Once a patient is sent home following hospital discharge, Seniorlink provides an integrated assessment that is for the care recipient, caregiver, and home. Seniorlink then develops a plan using SMART—specific, measurable, attainable, relevant, and timebound—goals. Seniorlink depends on care team commitment as a core component of the model’s success. Ms Tardiff said that Seniorlink designed a 2-day “Driving Clinical Excellence” Boot Camp for care team development, and all new care team members receive training upon hire.

Ms Tardiff said that the integrated assessment is best practice for the care recipient, caregiver, and home environment. Additionally, she said that the information allows the care team to evaluate risks across a broad range of medical, behavioral, and psychosocial domains, which include social determinants of health that are often the driving forces of risk in the population being served. And finally, based on the goals developed through the assessment, a unique experience for the care recipient and caregiver is created and results in improved outcomes and experience of care.

Seniorlink is a tech-enabled health services company that transforms care management in the home by balancing human touch and technology to improve outcomes and lower costs.

—Julie Gould