One of the most significant unmet needs is the lack of coordinated care and services for home and community-based service (HCBS) elders. When seniors are moved into a skilled nursing facility or assisted living care home, the facility is responsible for coordinating the care and for establishing a care plan specific to an individual’s clinical and social needs as well as their personal choices and preferences in care delivery. In the HCBS population, the patient, a caregiver, or a case worker bears the burden of coordinating the care. This is most often done in an emergency which may or may not have results congruent with the values and health priorities of the patient.

 

As technology advances and is made more accessible via smartphones, smart pads, computers, or security monitoring systems both for the person and for home; the care plan, itself, should be part of an electronic health record maintained by the patient or caregiver and portable between clinicians, patient, and caregivers. Using an application with cloud-based technology, we can develop a how-to-guide providing the user with tips on how to start the conversation with an elder and get the honest answers congruent with the elder’s social, financial, and clinical needs. It can provide an electronic platform for planning for current and future needs and examining options in the community for HCBS or congregate care now or later. The goal will be to design a blueprint for aging well, at home, and to pre-determine how, when, and where you seek medical treatment or transition to long-term care services.

 

 

 

 

 

 

Taking a cue from Frank Sinatra’s My Way lyrics, the MyWay® application guides the user to fulfill the verse “I planned each charted course, each careful step along the byway, and more, much more than this, I did it my way” (Sinatra, 1969). MyWay® is a cloud-based software and is included in the premium services offered by MyWay Aging Services, a fee-for-service consultant firm in the Northern Virginia area offering advice, solutions, and guidance on aging in place and long-term care services. MyWay® software includes worksheets, questionnaires, step-by-step guidelines, timetables, resources, a portable electronic health record, portals to upload medications, diagnostic tests, patient summaries, preventative care, etc. It can synchronize with other technologies used in the home or by the client which monitor health, medication, safety, activity, and other virtual assessment tracking tools. MyWay® helps the client develop a comprehensive care plan which aligns their care around patient goals and health priorities within the patient’s acceptable care preferences and financial means. MyWay® is dedicated to helping older adults receive coordinated care which meets their personal goals and preferences, is realistic based on family support, is financially feasible, eases the burden placed on caregivers, and decreases both fragmentation and the receipt of unwanted care that is of an unclear benefit. 
    

“Older adults with multiple conditions, complex health needs, and functional limitations are the major consumers of health care. These patients face a health care system that is often fragmented and inefficient; leading to care that be poor quality and high cost. Commonly cited causes of the fragmentation, high cost, and poor outcomes are a payment system on volume not quality, a delivery system that is fragmented across providers and settings, and a lack of attention to what matters to patients” (Blaum et al., 2017, p. 5). MyWay® care plan and portable electronic health record can offer peace of mind to seniors and their caregivers that clinicians will reduce unwanted intervention, have an advance directive on living not just end of life decisions, and help with communicating patient priorities.

 
Guiding Principles
    

There are four guiding principles for MyWay Aging Services and MyWay applications. These include:

1. Focus on goals and care preferences written in the patient care plan to drive care and communication. Clinicians and caregivers will align their attention based on the care plan. 

2. A team is established with roles and responsibilities defined and a blueprint of “if this, then this” scenarios are created, and resources identified and approved.

3. Anticipatory decisions, expectations, options, and other situational crises are prepared for in advance allowing for informed decisions before an acute situation occurs. 

4. Portable and shareable information highway which meets HIPAA & HL7 guidelines and privacy of sensitive information. 

 

To conclude, accountable care organizations and patient-centered medical homes are setting the stage for improving coordination of care. Currently, these cater mainly to disease-specific management. MyWay® is not care management, disease-specific, or applicable to advanced aging and end of life care. Instead, it is a conversation starter between seniors and their spouses, their children, or other caregivers. It is a how-to guide on aging well and doing it your way, not a rigid, impersonal plan. 

 

References:

 

Blaum, C., Tinetti, M., Rich, M.W., Hoy, L., Hoy, S., Esterson, J., & Ferris, R. (2017, March 1).     A research agenda to support patient priorities care for adults with multiple chronic conditions. Published by New York University School of Medicine and Yale University     School of Medicine as a White Paper presented to Patient-Centered Outcomes Research Institute. 
Sinatra, F. (1969). My Way. Music and lyrics. Retrieved from https://vimeo.com/91950218.