A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings

Knowing the person's needs, resources and preferences

Knowing the older person and his/her needs, resources and preferences was emphasized as an essential component of PCC. For instance, the incorporation of pre-specified and discretionary in-person home visits was essential, as this afforded the opportunity to visually identify a wide range of home and personal safety needs (e.g., fall risk, clarifying prescribed medications, risk of wandering), as well as the physical condition of participants and study partners.67, 68, 69 The personal care moment, interactive and step-wise increased the staff self-reported person centeredness and reduced their ‘stress of conscience’ by enabling them to provide the care and activities they wanted to provide.70, 71, 72, 73 Furthermore older people rated a person-centered environment as being in a hospitable, welcoming, safe, homely, neat and clean environment.74 The multicomponent supportive care programs to care for people with dementia at home improved the ability to age in place; the dementia care coordination model with the Maximizing Independence (MIND) at Home reported significant reductions in unmet care needs related to safety.67 These approaches represent an alternative to better prepare and interact with older people with dementia, addressing emotional and relational skills with PCC.72,73,75 The approaches emphasized strategies such as reminiscence, closeness, and connectedness with older people for matching “at the moment capabilities” that helped the older people to respond positively to contact offered and improve wellness.67,76, 77, 78, 79, 80

Goal setting through storytelling, shared power and responsibility

Health care providers and organizations need to promote PCC by engaging people in partnership, i.e., shared decision-making and participation.81,82 This was verified in a Swedish study with non-Swedish older people that focused on determining how they perceived leadership in the nursing home, while also focusing on the particular skills that staff chose as those required to lead PCC effectively and how this approach had or had not contributed to the level of the teamwork in the household.83

Shared power and responsibility were also observed when monitoring the quality of care involving both the older people and their families.81 Engaging older people in an activity-oriented/goal program showed that the residents met their personal goals related to, for example, self-care.84, 85, 86, 87 It was confirmed that the process of personal goal setting was a strategy in and of itself for increasing motivation toward achievement of the goals.84,88,89 The PCC further aimed to create encounters where participants support one another to make decisions in daily life to improve their overall health.83 Engaging older people with these client-centered interventions that were tailored to meet the specific needs of the person aimed to increase basic activities of daily living, improve health-related quality of life, nutrition and mobility; decrease bodily pain; alleviate constipation; and prevent functional decline, depressed mood, and admissions to hospital for acute care.69,84,87,90, 91, 92 A face-to-face motivational approach, along with the provision of information and advice by geriatrician and nurses to older people with chronic diseases who were being treated by polypharmacy, clarified prescribed medications and seemed to improve the level of medication taking.93 The interventions meeting goals for preference fulfillment improved the quality of care and quality of life.94 In addition, the preference for everyday living intervention showed “having regular contact with family” as an important priority. Having privacy, choice about what to eat, when to bathe, and activity options were also important preferences for most of residents.94 However, other interventions such as the “Multi-method program”, did not show the effectiveness of each single intervention.92 This is a good example of “one-size does not fit all”.95, 96, 97 Advance Care Planning —including the patient ‘storytelling’ approach that brings the focus back onto the person— encouraged the older people to communicate their preferences and mitigated their existential distress, in both older people with chronic conditions and, particularly, in those at the end of life.82,94,98,99 The “On the Move” program focused on the timing and coordination of movements critical for preventing functional decline and disability without any increased risk to the older people. In this program, older people and stakeholders were involved in the design and execution of the study, and it was found that it is critical to build lasting relationships and that it was therefore important “to take the time to listen to and socialize with the resident.”82,89

Communication based on relationship, trust and respect

Mutual communication characterized by trust and respect was found to be a cornerstone in all the interventions, and they were also dependent on the older person's cognitive function and the staff's skills in communicating with those who were cognitively impaired.77,99 Some of the interventions focusing on reaching specific goals or needs of the older people did not appear to engage the staff in iterative communication where the patient could tell the story or improve his/her self-determination. These interventions did not give older people a voice to prioritize their goals.96,100 Home-based programs addressed specific or multiple and varied needs of older people with chronic health conditions and have customized the specific services to the older people, leading to a positive effect on diverse outcomes such as an improvement in daily activities of life, nutritional status, incontinence, physical condition, or mood.82,86,87,92,95, 96, 97,101, 102, 103, 104, 105, 106, 107 The exercise-based programs, i.e., task-specific exercises —focusing on, e.g., muscular strength, coordination and cognitive function— had a greater impact on older people with mild cognitive impairment than on those with moderate to severe cognitive impairment.86,88 Exercise improved function in frail older people,97 resulting in reduced depressive symptoms in older people with depression compared with usual care.108 Trials of activity programs in the community have also yielded increases in activity levels but without improvement or changes in quality of life, self-management outcomes, or depression.86,92,109,110 Person-centered training promoted interdependence, trust and reciprocity as a basis for older people with low cognitive function —and their families— to engage in a partnership with staff.77,89,104,111 The individualized interaction between the older person and the staff helped older people with dementia to cope with their fears, agitation, aggressive behavior and isolation.68,71,72,76,78,79,112 Additionally, individualized interactions involving the family and care assistant significantly improved positive interactive behavior of care-dependent older people with dementia.73,76,78,81

Conducting a tailored personal health plan through relation-based approaches

Creating a tailored personal health plan was an essential component in implementing PCC.111 Trusting relational practice and engagement to know the person as a whole113 through respectful dialogue with the person and his/her relatives were among the other prerequisites for conducting the tailored care plan.114 The dialogue with the older people was practiced by carefully listening to the older people's description and experiences of the illness and life situation, in order to get a better understanding of their needs, problems and wishes.111 A nuanced care plan enabled the older people to have more control over their own life situation,114 supported them in their daily routines and reinforced their capacities to self-manage.111 Among the crucial prerequisites were the older people's narrative of their own experience,115 attention to their bodily and existential needs,116 involvement of the older person and their relatives in the planning of care,117 and the sharing of information and decision-making via interdisciplinary team meetings.111,114

Knowing the older person as a whole

Creating a well-functioning relationship between the older people, their relatives and the staff was among the crucial components in developing PCC.118 The professionals appreciated the relation-based practice, which raised their awareness of diversity in its broadest sense.119 For example, role-play scenarios in drama-based education increased the practitioners’ awareness, insight, patience and optimism with regard to supporting the older people with dementia in their strive towards an independent life.114 The professionals realized that the older people are not a homogenous group and therefore “one size does not fit all”.119 Appreciating this made it possible to know every single person's reality, which was described as a more nuanced effort beyond culture, gender, race, and religion. Research indicates that embedding awareness of diversity in practice can be achieved through active listening and respectful communication.119 Applying relation-based practice increased the professional's confidence and stimulated a behavioral change toward being less prejudicial of older people based on their associated stereotypes.119 There was another point related to knowing the patient as a whole — that is, the intention to avoid reducing the patient to his/her disease/diagnosis. Furthermore, emphasis was placed on the significance of understanding the illness from the patient's perspective, giving spaces for the patient's voice and comprehending how the disease affects the patient's entire life situation.99 The professionals underlined the importance of “all little things” that they expressed or did to confirm the older patient as a person.119 For example, integrating the older person's life history into the conversations was among the efforts made to recognize the patient as an unique person.120 However, knowing the older people with dementia as a person was challenging and depended on the professional's authentic engagement in establishing professional relational practice and discovering the person's life history, priorities and wishes.121 The importance of shifting from a task-oriented approach to person-centered relational practice with the older person was underscored by professionals.113

Confirming the older person as part of the team

Partnership as a co-creation process was crucial in implementing person-centered teamwork, which was perceived as both a limiting and improving factor for change in individual behavior and organizational procedures and policies.119 User-involvement was an intention that was appreciated by the staff, and is one that requires a flexible approach, including spending sufficient time and having patience during the initial stage of an intervention.122 This long-term process required a modification in the professional's attitudes and practice — a transition from “doing for” to “doing with”122 and from “providing” to “co-creation”.119 A well-functioning interdisciplinary relationship and cooperation between the older people, their relatives and the staff118 were among the crucial prerequisites to create a tailored care plan and to follow up on planned goals.111,119 This minimized overlapping tasks but was perceived as time-consuming.111 Continually adapting co-creation processes could increase users’ awareness of their own potential for improved activities of daily life function through professional user meetings and the inclusion of dialogue with open-ended questions, active listening, and appreciation of users’ views.122

Inter-professional consultation and co-creation

Older people's involvement in decision-making regarding their own care was another essential component in PCC, which required attentive engagement and a trusting relationship.121 Frail older people appreciated their independence, and preferred taking their own decisions and finding solutions by themselves.111 Mechanisms that support older people's involvement in decision-making include actions aimed at (i) increasing the older people's autonomy, control and privacy123; (ii) ensuring that they are taken seriously by health care professionals111; and (iii) providing appropriate information and patient education.114,116 Establishing the basis for decision-making was challenging for health care professionals caring for people with dementia.121 Having an inter-professional teamwork and consultation with the older people, their support networks and key relationship was essential to accurately interpret the person's needs and wishes and thereby involve the person in a meaningful decision-making process.121 Furthermore, relation-based care of people with dementia was practiced through forging a friendship, sharing experience, developing trust and feeling appreciated, as well as taking time and making time.124 Relational care through the shared experience of living with dementia connected and developed bonds with others and helped people to feel a sense of safety and equality, which led to development of trust and appreciation among community health care staff, people living with dementia, and family care partners.124 In addition, factors such as having greater flexibility, staff education and developing skills to engage older people in decision-making were highlighted.125 Studies emphasized the impact of the involvement of older people and their relatives in the creation of an education package to meet needs and take diversity into account,126 building tailored care plans and sharing both information and decision-making by an interdisciplinary team.111,116

Enhancing the older person's capabilities, supporting preventive care and facilitating self-care

Another essential component of PCC was to support the older people in their self-care and enable them to remain independent.111 Frail older people desired to remain independent; they preferred to take their own decisions and to find solutions by themselves in order to have more control over their daily lives.111,127 Accessibility was another important aspect in self-care, which was described in the following terms: older people's access to transparent information about available services; the impact of such services on their health; how to navigate within the health care system; cultural and social factors that affect older people's acceptability; as well as autonomy and capacity to choose appropriate health care services. Furthermore, whether health care services are available and can be reached physically in a timely manner —together with the economic capacity of frail older people to spend their time and resources using health and social care services— were described as factors affecting accessibility.127

From the patient's point of view, a person-centered approach was characterized by: being taken seriously as a ‘worthy’ person by the health care professional with resources and capacities,111,122 being part of the team,119 being involved in decision-making,121 being supported in self-care and maintaining independent lives.111 PCC was described as a shifting focus from reactive care to proactive and preventive care,113 supporting older people's connection to everyday life, which increased their feeling of well-being and enhanced their capabilities to be ‘in charge of’ their self-care.111,116

Managing of competing values in the team by engagement, professional friendship and keeping distance, a flexible organization and situational leadership

Competing priorities in clinical and organizational practice were perceived as a hindrance to the goal of achieving PCC; for instance, the conflict between safety and autonomy117 — or, for example, being effective and working quickly according to old traditional practices competing with the time required to facilitate user's involvement.122 Rules were discussed as an area of focus to avoid rigidity and improve flexibility in care plans. In addition, limited resources —particularly staffing— were commonly mentioned as a reason for lack of follow-through on the older person's goals.117 Perceived conflicts between PCC and medical care were the most frequently reported source of arguments among physicians and nurse practitioners.125 Supporting the resident's and their family's involvement in care planning through regularly scheduled care conferences, and informal engagement between residents or family members and staff in the form of an open door policy were emphasized. Furthermore, the importance of broad commitment across staff roles to the overarching principle of PCC was highlighted.117 In post-acute care situations, the importance of health/medical goals over the older people's preferences needs to be explicitly documented in care planning in order to reduce doubt and perceived conflicts.125

Having a person-centered leadership, a flexible organization and an ongoing critical reflective process to facilitate person-centeredness among staff were among the most important prerequisites for implementing PCC.128 Changing the focus from “doing” to “being” person-centered was stressed, as was building a functioning and integrated team through collaboration, open communication, appreciation and trust.128 A person-centered foundation was characterized by a combination of developing culture and transformational leadership. In addition, the supportive organizational systems put in place to achieve these changes and the practitioners were open to learn from each other and there was a high level of interaction between older people and organizational management to enable practitioners to identify and resolve issues by themselves.115

Appropriate person-centered communication skill and documentation

The importance of appropriate person-centered communication was underscored.120 Person-centered communication was characterized by four indicators: first, to recognize older people as each being a unique person by incorporating their life histories into conversation; second, to negotiate about older people's preferences, desires and needs by consulting them and their relatives; third, to facilitate older people's involvement in the conversation or action; and fourth, validation — which involves expressing and understanding the feelings of the older people with dementia.120 The importance of communication and collaborative skills in motivating and stimulating older people to improve their self-management abilities and independence —such as listening and asking the right questions, understanding implicit messages, and providing feedback— was also emphasized.113 Additionally, allowing sufficient time, speaking clearly and directly, explaining the different options available, pausing to allow the person to process information and repeating information were among the professionals’ communication skills and strategies designed to enable a person with dementia to be meaningfully involved in decision-making.121 Furthermore, “listening to the other person with the heart” by being alert and giving the other person full attention128 and also “being attentive to non-verbal cues” were among other important points regarding person-centered communication.121 Providing PCC was experienced as a learning process that delivered opportunities for personal and professional growth; for instance, attentive listening was undervalued by the staff at the start of the intervention and was described as actually doing nothing, but staff members later realized that attentive listening was indeed “doing something”.113

Building a trusting relationship by taking sufficient time, being attentive, and by keeping their promises113 and confirming the individual as a person by calling him/her by name reinforced the sense of self.120 Furthermore, creating a sociable atmosphere enhanced the sense of connectedness and partnership.113 There were contexts in which missed opportunities for person-centered communication occurred; for instance: when the older person said something but the staff member ignored it and/or moved onto the next topic; when staff began and ended their interactions; when staff members told older people what to do without providing options or without inviting their help in completing the task; when staff did not ask for permission prior to performing an action; when staff members failed to acknowledge the older person's feelings, uncertainty, distress, discomfort, lack of confidence or self-deprecating emotions.120

Many nursing records were incomplete and information regarding psychosocial aspects of care was often lacking, despite the fact that value was placed on documentation of the person's involvement in the health care processes, shared decision-making and care plan.129 The nursing documentation was not completed in partnership with the older people. Nevertheless, documentation focusing on the older person's beliefs and values was perceived as a factor promoting more meaningful relationships between nurses and older people.129 Formulating and documenting a tailored personal care plan through interdisciplinary cooperation minimized the overlapping of tasks. Digitalization may avoid such task overlap, facilitate the exchange of data with other professionals, reduce time-consuming tasks, and increase interdisciplinary cooperation.111