MyWay Concept Development

One of the most significant unmet needs, in my opinion, 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. The development of a care plan where the patient, caregiver, case worker, and clinicians can work from is paramount to making decisions that meet both the medical and social needs of our elders remaining at home with support.

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 institutional care needed 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 goal’s 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 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.

About the Author:

Donna Rein lives in Northern Virginia with her husband, 2 teenage boys, her mom, and a labradoodle. Donna graduated from Virginia Tech with a B.S. in Education and taught special need’s children in DC before moving to the long-term care sector. Donna became a licensed nursing home administrator in Virginia in 1989. She was dual licensed in North Carolina for a period of 10 years before returning home to Virginia and continuing her long-term care career first in Richmond and then relocating outside DC where she lives currently. Donna left long-term care administration in 2007. She has spent the last 11 years home with her husband and boys. In 2015, Donna’s mother suffered a massive hemorrhagic stroke leaving her paralyzed on her left side and unable to continue to manage independently. Post rehab, Donna’s mom moved in with her and her family. Donna’s role went from provider to caregiver. After experiencing disappointment and frustration with home & community-based services to help ease the burden of caregiver stress and burnout, Donna decided to enroll in a post-graduate program and pursue her master’s in health administration (MHA). Today, Donna is half-way through her master’s program and has dedicated herself to finding innovative solutions to the aging health system failures. Using her knowledge and skill set from the many years of working for and with the aging population and her new understanding of the fragmentation of providing care to loved ones at home, Donna hopes to launch a toolkit for seniors and their caregivers.