an article of
Susana Calero Boza, Carme Masgrau Ponsatí, Eva Serrat Graboleda and Maria del Carmen Malagon-Aguilera,
of the Col·legi Oficial d’Infermeres i Infermers de Girona ()
The World Health Organization (WHO) recognizes that the comprehensive and person-centred care strategy it should be the axis to improve health and long-term care services (WHO, 2015). In its Decade of Aging 2020-2030, it reiterates that in order to foster a healthy aging and improve the lives of older people, in addition to introducing changes in the actions we undertake, we must also change our way of thinking about age and aging.
To this end, the Decade proposes four areas of action, one of which is offer integrated care centered on the elderly (WHO, 2020). This article intends to review Person-Centered Care in Gerontology. Our objective is to summarize the origins and evolution of this model and to investigate how and to what extent it has been applied in our environment.
Evolution of the construct until the paradigm shift
The WHO in 1948 defined health as a complete state of physical, mental and social well-being and not only how the absence of conditions or diseases. Currently the definition is maintained, but the concept has evolved towards understanding health as a process rather than a state. A process between well-being and quality of life and disease, a continuum where the person moves conditioned by the social determinants of health and by the personal, community and social resources to which they have access. This new paradigm is based on the promotion of people’s health and the salutogenic model (Lindstrom and Eriksson, 2010).
In turn, the transformation of society, life expectancy, globalization, advances in equality, civil and social rights raise reflection on a new care model that take into account all these changes and that they adapt to the definition of health proposed by the WHO.
At the United Nations World Assembly on Aging held in Madrid in 2002, the WHO proposed a political framework for “andactive aging” based on the three pillars: health, safety and participation (United Nations Organization, 2003). In 2006, Spain, with the impetus of Organic Law 39/2006, of December 14, on the Promotion of Personal Autonomy and Care for people in a situation of dependency (LAPAD), made social services the fourth pillar of the system of social welfare.
This manifesto raised a new care model based on comprehensive care. It highlights the contribution of Pilar Rodriguez (Adviser to the Ministry of Health, Social Policy and Equality) one of the referents of the person-centered care model in Spain, which prepares the document “Comprehensive and person-centered care” where he exposes the principles and criteria that support a model of intervention in disability, frailty and dependency. (Rodriguez, 2013).
In Catalonia, Teresa Martinez Rodriguezprepared a document paying attention to the PCA model in the gerontological field, where it reflects the practical way of applying and evaluating it. For the author, the ACP model gives a central role to the users, being them the center of attention and, therefore, of the organization and of the care processes, it is each person, from the recognition of their dignity as a human being and from respect for their life project (Martínez, T, 2016).
Fundamentals of the comprehensive and person-centered care model
Rodríguez (2013) proposed the definition of person-centered comprehensive care that is transcribed below: “Comprehensive and person-centered care is what promotes the necessary conditions for the achieving improvements in all areas of the quality of life and well-being of the person, based on full respect for their dignity and rights, their interests and preferences and counting on their active participation. (p.74)”.
The same author proposes a series of beginning (Dignity and rights) and criteria (ethical values) that should be taken into account when proposing interventions based on the comprehensive and person-centered care model (AICP Model). Next, figure 1 graphically represents the AICP model proposed by Rodríguez (2013).
Figure 1. Principles and criteria to base a comprehensive care model centered on the person. Source: Rodriguez (2013)
This model involves investment, benefits, management and organization of diagnostic, treatment, care, rehabilitation and health promotion services. The key aspects to be improved are: organization culture (reinforcing teamwork) and the coordination between care levels. The basis of the structural elements of work must be the clinical history and the respect for the rights and dignity of the person. Professional practice must go through a periodic methodological screening of the actions, techniques, instruments and protocols to verify that they are consistent with the principles (Rodríguez, 2013).
Application of the Person-Centered Care model in Gerontology
Throughout the years, in Gerontology, different approaches have been configured to refer to the aging of people, but without a doubt, the bibliography in recent years focuses on the PCA model, hence applied to the field of gerontology, is called the model of Person-Centered Gerontological Care (AGCP). The increase in life expectancy and, therefore, the growth in the number of elderly people in this country makes the revision of the care model in gerontology acquire special relevance.
The Person-Centered Gerontological Care Model seeks to harmonize the organizational systems of the services, with the preferences and desires of the elderly who require attention or personal care (Martínez, 2011, 2016) and from this approach, the management of centers or services must be subordinated to objectives related to the person’s quality of life (Suarez, 2020).
Next to agingis usually joined chronicity of many pathologies, which is why health systems must reconsider the two main objectives of care for this segment of the population, diagnosis and cure, accepting that very often it is necessary to change the focus of the ends and go from healing to care. (Rodriguez, 2013).
The role of Primary Care Teams (EAP) is essential to achieve these objectives, since it is the professionals of these teams who are the protagonists of the training for self-care and the training of family members to carry out the care (Rodríguez, 2010). Has case management, led by nurses, is particularly relevant. In this line, the WHO (2019) has prepared a report with the pertinent indications to make the application of the gerontological PCA a reality at this level of care. At the state level, they are referents in our country in the application of this model, the and .
Together with Pilar Rodríguez, another of the leading authors in the definition and application of the Person-Centered Care Model in Gerontological Services is Teresa Martínez (Ministry of Social Services and Rights. Principality of Asturias), who suggests in her Centered Care model in the Person in Gerontology (ACP-gerontology) that should be taken into account the multidimensional approach to the constructso that it does not end in a set of interventions and isolated and unconnected proposals without taking into account the globality of the organizations involved in care for the elderly (Martínez, 2011).
In its most recent contributions in 2019, it proposes to adapt the gerontological centers that provide long-term services taking into account two dimensions. The first dimension is called Person-Centered Practices, which encompasses a set of actions based on the interaction between professionals and the elderly people cared for. The second dimension is called Enabling environment, which refers to the elements of the environment and facilitate the effective application of person-centered care. Based on these, he proposes 50 key actions that are considered highly relevant (Martínez, 2019).
AGCP assessment instruments
In order to determine if the interventions and proposals that are currently carried out are really part of the PCA model and if they really have an impact on the quality of care provided to older people who use gerontological services, we need to have assessment tools.
De Silva (2014) points out that the most used strategies in the evaluation of health services from the PCA approach are the systematic observation of the care provided, the surveys aimed at users of services and surveys of professionals. The same author points out that using a single instrument could lead to errors since the PCA is a complex and multidimensional construct, so it is not prudent to recommend using a single instrument. It is also important to take into account the triangulation of opinions among users, family members, and professionals, to reduce the biases that could occur when using only self-assessment measures. (DeSilva, 2014)
Regarding evaluation instruments for person-centered geriatric care, we find several internationally (Martínez, Suárez-Alvarez Yanguas, 2016; Suárez, 2020). There are, in turn, several qualitative instruments with the aim of guiding gerontological services that are in the process of changing their model. Most of the qualitative methodology tools have limitations, since reliability or validity data have not been reported, but they are interesting for generating self-assessment ideas and facilitating improvement proposals in the teams (Martínez et al., 2016).
In Spain, the number of instruments available, created in our country, or validated translations into Spanish is considerably reduced, finding in our bibliographic search only 8, of which 5 are addressed to professionals, 1 to people with dementia, 1 to users of gerontology services and another to the relatives of the users. Table 1 below shows a summary of the most outstanding characteristics of the available instruments and validated in Spanish.
Table 1. AGCP Assessment Instruments in Spain ordered by publication date
Own elaboration based on Suárez (2020), Martínez et al (2016). Martínez et al (2019) and Martínez et al. (2021)
conclusions
In Spain, the ACP Model began to be relevant when it came to plan strategies and resources from the middle of the first decade of this XXI century. Progressively, this model has been adopted in different areas of health services. This new approach to healthcare has shown clear benefits in both quality of care provided to users as in the levels of well-being…