Person-Centered Gerontological Nursing: An Overview Across Care Settings

Residential Care Settings

PCC is common vernacular in residential care practice and policy. Through the Nursing Home Reform Act and the Omnibus Budget Reconciliation Act, PCC was introduced to improve the quality of care in nursing homes. The resulting culture change movement encouraged models of care that meet a person's holistic needs via care practices and the physical environment (Li & Porock, 2014).

Approaches. The Pioneer Network is a leader in the culture change movement in conjunction with organizations such as the Eden Alternative and Green House Project. The Eden Alternative provides international education and support on PCC and environments to improve quality of life for older adults, emphasizing the transformation of the physical environment to be more home-like with plants, animals, and intergenerational activities (Li & Porock, 2014). Similarly, the Green House Project aims to promote PCC through the empowerment of certified nursing assistants (CNAs; e.g., participation in decision making at the person level) and the transformation of the physical environment to small communities to promote meaningful social and therapeutic interactions (Li & Porock, 2014; Robinson & Gallagher, 2008).

For residential settings in the United States, PCC models are embedded in regulatory requirements by the Centers for Medicare & Medicaid Services (CMS). CMS requires PCC that supports residents' autonomy and decision-making (CMS, 2018a,b) and recently changed their payment system (e.g., Patient-Driven Payment Model [PDPM]) to reflect the importance of PCC as an integral aspect of quality care. In the new payment system, instead of compensating providers based on the volume of services provided, the PDPM reimburses providers on the accuracy and appropriateness of services for care recipients, emphasizing the importance of personalized care.

In some states, person-centered pay for performance initiatives have been integrated into practice to promote PCC practices. In Kansas, the Promoting Excellent Alternatives in Kansas (PEAK 2.0) program, supported by the Kansas Department of Aging and Disability Services and Kansas State University, is used to encourage PCC practices among nursing home staff, especially nurses (Kansas State University, 2019). Similarly, the Ohio Department of Medicaid (2015) previously implemented a pay for performance initiative requiring nursing homes to implement the Preferences for Everyday Living Inventory (PELI) to measure residents' preferences for daily living. Interventions such as PEAK and PELI have resources available for nurses to enhance the person-centeredness of their practice along with PCC trainings and tools to honor residents' choices and engage residents in care (access https://www.hhs.k-state.edu/aging/outreach/peak20/pcc-resources; https://www.preferencebasedliving.com).

Outcomes. Practice and policy initiatives in residential care have resulted in improved outcomes for residents and staff. Literature suggests increased time and interaction between residents and staff, particularly direct care staff, can improve job satisfaction and lower turnover (Vermeerbergen et al., 2017). Person-centered interventions have been linked to better outcomes in older adults, including care satisfaction, well-being, and less behavioral symptoms and reliance on drug interventions to control symptoms (Li & Porock, 2014; Poey et al., 2017).

Due to the regulatory environment in residential care and movement toward PCC models, nurses in the residential care setting are required to deliver PCC. By accessing resources and using specific intervention, such as PEAK and preference-based care, nurses can enhance the person-centeredness of their practice and positively impact residents' care experiences (Kansas State University, 2019; Ohio Department of Medicaid, 2015).

Home- and Community-Based Care Settings

Although PCC has been widely adopted in residential care, most older adults prefer to reside in their homes for as long as possible (Binette & Vasold, 2019). However, PCC is still evolving in home- and community-based settings, and work remains to fully understand gerontological nurses' approaches and outcomes in these settings (Ruggiano & Edvardsson, 2013).

Approaches. The most common applications of PCC in home- and community-based settings are the Patient-Centered Medical Home (PCMH; Jackson et al., 2013) and Patient Priorities Care Model (PPCM; Blaum et al., 2018). The PCMH is a transformation of primary care toward improving patient and informal caregiver experiences, outcomes, and interactions within the health care system (Jackson et al., 2013). Basic tenets of PCMH include a patient-centered focus, care coordination across health care team members and settings, and emphasis on care quality and safety (Jackson et al., 2013).

The PPCM is a care process designed for older adults with multiple chronic conditions aimed to align care with patient goals and values. PPCM uses a structured process where a facilitator guides the person to identify their (a) health outcome goals and (b) care preferences (Blaum et al., 2018) and then discuss their goals and preferences with the interdisciplinary team to create a personalized care plan.

Outcomes. Using PCMH in home-and community-based care has resulted in increased access to care, better continuity of care across providers and settings, improved patient self-management and involvement of care, and increased use of health information technology in care (Arend et al., 2012). Outcomes such as improved care recipient and caregiver satisfaction, lowered burnout and stress among health care staff, and fewer hospitalizations and emergency department visits have also been reported (Nelson et al., 2014). However, evaluation of PCMH has primarily included person-level interventions or aspects of the model, rather than comprehensive program evaluation, and many outcomes are seemingly dose dependent (Nelson et al., 2014; Rosland et al., 2018). To date, primary care physicians have led care coordination in the PCMH model, but there is an opportunity for gerontological nurses to shape how PCMH can look in primary and home- and community-based care.

PPCM processes in home- and community-based settings are associated with better alignment of individuals' priorities, reduced treatment burden, and fewer added medications (Ferris et al., 2018; Freytag et al., 2020). As PPCM becomes more widely implemented, nurses have the opportunity to establish themselves as integral in the PPCM process. Nurses are well-suited to serve in the role of facilitator to help elicit people's priorities and guide them through the development of a personalized care plan (access https://patientprioritiescare.org/resources/publications for training and resources).

Acute Care Settings

The integration of PCC into acute care settings is multifaceted and challenging. However, understanding how to provide person-centered nursing care for older adults who are acutely and complexly ill is needed. Expectations, self-care knowledge, and skill of older adults in acute care and their families have risen, creating a need to change how acute care is delivered.

Approaches. Changes in acute care toward PCC include (a) the progressive patient care model; (b) the person-centered approach; and (c) the lean approach (Gabutti et al., 2017; Yevchak et al., 2017). The progressive patient care model shifts from traditional clustering of patient-based care on a specific disease process, such as telemetry, to pooling patients together based on the amount of care they require. Examples of these models of care include assigning levels of care to patients using a numeric rating scale; grouping patients by more standard sets, such as outpatient and inpatient surgeries; and stratifying inpatient surgical candidates based on expected length of stay (Gabutti et al., 2017; Villa et al., 2009; Villa et al., 2014). Person-centered approaches emphasize the need for improved communication and continuity of care across providers and settings of care (Gabutti et al., 2017). Except for emergency departments, relatively little of this work has focused on communication and care transfers within acute care settings (Gabutti et al., 2017). The lean approach was originally created as a way to decrease unnecessary steps and waste in engineering and manufacturing processes (Nicosia et al., 2018). In acute care settings, the lean approach focuses on improving patient flow by redefining health care team members' roles and expectations, changing staffing models and scheduling, improving communication among staff, and redesigning workspaces (Gabutti et al., 2017). Ways to achieve these changes toward PCC in acute care include information communication technology, managerial accounting, and human resource management tools.

In addition to Gabutti et al.'s (2017) work, Fiorio et al. (2018) support the need for organizational and nursing models of care to achieve more person-centered acute care. To shift toward PCC, a process-driven model, such as primary nursing, is needed to reduce fragmented care (Vos et al., 2011). Typically, in acute care, functional or team nursing where a group of nurses are responsible for each patient's care is employed. However, primary nursing means one nurse holds responsibility for the coordination and delivery of care throughout hospitalization to provide continuity of care (Dal Molin et al., 2018; Fiorio et al., 2018; Vos et al., 2011). The primary nurse's role may also shift from providing direct care to a nurse liaison or advocate, where the focus is on care coordination and communication among the patient, family, and all health care team members (Gabutti et al., 2017).

Outcomes. Evidence on patient and nursing staff outcomes related to implementing person-centered approaches in acute care has mainly been positive. Staff experience decreased turnover, and patients have fewer pressure ulcers, falls, and urinary catheter infections (Dal Molin et al., 2018). Patients also report that primary nursing results in more tailored care to their needs and preferences (Naef et al., 2019). However, evidence also suggests that changes within organizational and nursing care delivery models result in increased workload and burden on nurses (Gabutti et al., 2017).

A potential explanation of the variance in primary nursing outcomes is similar to those explored with other PCC setting-specific approaches; the implementation and uptake of primary nursing is inconsistent and often done without appropriate system and organization supports (Naef et al., 2019). Additional evidence is needed on how primary nursing impacts outcomes for older adults and their informal caregivers, particularly for those with cognitive impairment, dementia, and/or delirium.