Person-centered care (PCC) is a standard for healthcare delivery in the United States. This concept considers appropriate evidence-based treatments and the patient’s values and beliefs. However, there are often areas of fragmentation in integrating these concepts into practice. Because of disease, chronic health needs, or lack of supportive resources, older individuals are often transferred through different levels of care in the healthcare delivery system. This can become a revolving door of transfers between levels if individual needs are not all addressed, causing patient needs, values, and social communication to become disrupted. Additionally, errors may occur with information transmitted between levels of care.

Read the following scenario and answer the following questions:

Mr. H is the 80-year-old widower at the Nursing Home. He prefers being outside the facility boundaries to look for items. The facility developed a PCC plan to meet his needs. However, not much detail was reviewed in the plan that was developed. We will further enhance this plan.

You are the advanced practice nurse coordinating care for Mr. H.

1. What physical, emotional and cognitive concerns would you consider in developing a plan for this individual?

2. What specific tools could be used to evaluate the needs of a person with dementia?

3. Who would be included in developing the plan? Why did you choose them?

4. What social, financial, and goals of care would you consider? Why?

5. What community resources could be helpful?

6. How would you communicate the final plan to others involved?

7. How could you evaluate the effectiveness of the plan? If effective, how would you sustain it?