A Preference-Based Model of Care: An Integrative Theoretical Model of the Role of Preferences in Person-Centered Care

Abstract

Knowledge of individuals’ everyday preferences is a cornerstone of person-centered care (PCC). Initial evidence demonstrates the positive impact of honoring preferences in care for older adults receiving long-term services and supports (LTSS). Yet, the mechanisms through which preference-based care affects individual well-being remain poorly understood. This article proposes a theoretical model of PCC entitled the Preference-Based Model of Care that integrates the Theory of Human Motivation, Self-determination Theory, the Competence-Press Model of person and environment fit, the Living Systems Framework, and the Broaden-and-Build theory of positive emotions to deepen our understanding of the processes through which preference-based care affects well-being among older adults receiving LTSS. The Preference-Based Model of Care illustrates how goal-directed behaviors facilitate need fulfillment through the expression of individual preferences and how these behaviors mediate the relationship between person–environment fit and affect balance within a particular social, cultural, and political context. The Preference-Based Model of Care can advance research on PCC in LTSS and can inform LTSS clinical practice guidelines for older adults, regardless of functional or cognitive capacity.

Recent calls from the culture change movement in long-term services and supports (LTSS), the Centers for Medicare and Medicaid Services in the United States, and healthcare institutions abroad emphasize the need to “know the person” in order to deliver holistic care (Centers for Medicare and Medicaid Services, 2013; Edvardsson & Innes, 2010; Fazio, Pace, Flinner, & Kallmyer, 2018; Institute of Medicine, 2001; Koren, 2010; The Health Foundation, 2016). The shift from a medical model toward one that places importance on psychosocial needs and identity is seen as central to improving care for older adults receiving LTSS. Knowledge of individuals’ everyday preferences is a foundation for person-centered care (PCC). While empirical evidence supports the benefit of providing care tailored to preferences (e.g., Barbosa, Sousa, Nolan, & Figueiredo, 2015; Gerdner & Schoenfelder, 2010; Gitlin et al., 2017; Van Haitsma et al., 2015), the mechanisms through which preference-based care results in positive outcomes have not been well-developed. A supportive theory is lacking.

This article takes a multi-step process to propose a Preference-Based Model of Care, a theoretical model that articulates the processes and consequences of delivering preference-based care to older adults. We first provide a narrative review of PCC and the meaning of preferences as expressions of needs, values, and goals. We then discuss five theories that inform our understanding PCC. Finally, we propose a new Preference-Based Model of Care and provide a case example that outlines the mechanisms through which preference-based care affects older adults’ psychological well-being. We propose this model to inform the testing of hypotheses for research directed at improving the affective well-being of older adults receiving LTSS.

PCC and Preferences as Expressions of Needs, Values, and Goals

PCC is a philosophical framework that guides delivery of healthcare and is based on individuals’ values and preferences (Fazio et al., 2018). The term PCC evolved from Kitwood’s (1997) philosophy that “the person” should always be the first consideration in the delivery of dementia care. More recently, the American Geriatrics Society (2016) produced a consensus definition specific to older adults that states that “individuals’ values and preferences are elicited and, once expressed, guide all aspects of their healthcare, supporting their realistic health and life goals” (p. 16).

Within this frame, the term preference can be used broadly to describe a person’s tendency to consider something as (un)desirable in a particular circumstance (Zajonc, 1980). More specifically, a stated preference is an expression of the attractiveness of an option that serves to fulfill a person’s needs, is determined based on one’s values, and directs behaviors to achieve goals (see Figure 1; Coolen, Boelhouwer, & Driel, 2002; Warren, McGraw, & Van Boven, 2011). Needs are biological, social, and functional in nature and conceptualized as inherent to individual existence (Coolen et al., 2002); they move individuals to action and are essential to maximizing healthy functioning. Maslow (1943) famously outlines five levels of need: physiological, safety, belongingness and love, esteem, and self-actualization. Focusing more narrowly on psychological needs, Deci and Ryan (2000) specify three innate needs for psychological well-being: autonomy, competence, and relatedness.

Figure 1.

Defining the relationship between values, goals, needs, and preferences.

Needs are then transformed to become values or self-configured principles that guide individuals’ behaviors (Coolen et al., 2002). Individuals place differential importance on values and create a unique configuration, or system, that guides actions. Values may fluctuate based on circumstances, but value systems typically remain stable (Coolen et al., 2002). Goals are the desired (un)conscious outcomes of one’s behaviors based on one’s values (Warren et al., 2011). A preference for something or someone over another, therefore, often indicates a differentiation in the values ascribed to people, places, experiences, or sensations of the individual and his/her sought after goals (Warren et al., 2011). A preference for a specific activity or choice over how to spend one’s time, for example, is informed by one’s broader value system and behavioral goals and reflects the daily expression of how an individual would like his/her psychological and physiological needs to be met. Preferences are thus an integral measurement tool to operationalize more abstract constructs (i.e., needs, values, goals) of individuals. Table 1 depicts the operationalization of preferences to better understand the hierarchical structure of needs, goals, and values evident in preference assessment.

Table 1.

Example of Preferences Serving as Operationalizations of Needs, Goals, and Values

Preference question	Need*	Goal	Value†
How important is it to you to choose your own bedtime?	Autonomy	To make one’s own decisions about how much sleep is deemed personally necessary for optimal functioning.	Control
How important is it to do things with groups of people?	Relatedness	To socialize, network, or connect with other people.	Relationships
How important is it to you to have reading materials available to you?	Competence	To stay informed of what is going on outside in the world.	Self-identity

Notes: *Exemplar needs outlined here are drawn from Deci and Ryan’s (2000) Self-determination Theory.

^†Exemplar values outlined here are drawn from McCullough, Wilson, Teasdale, Kolpakchi, & Skelly (1993) and Reamy, Kim, Zarit, & Whitlatch (2011).

In the context of LTSS, the process of constructing preferences relies on both intuitive (i.e., self-awareness) and deliberate (i.e., choice) processing by older adults of their needs, values, and goals (Dhar & Gorlin, 2013). Preferences are shaped by past experiences, the contextual characteristics of the environment, complexity of the decision task, the quality of options, how a preference is elicited, and how options are presented (Bettman, Luce, & Payne, 1998; Hoeffler & Ariely, 1999; Warren et al., 2011). Preferences cover a broad range of behaviors and activities related to daily life, such as leisure activities, growth activities, caregivers and care, social engagement, and activities of daily living (Van Haitsma et al., 2013). Preferences in LTSS are the expressions of known values including Environment (e.g., maintain personal property), Self-identity (e.g., maintain continuity with the past), Autonomy, and Control (McCullough, Wilson, Teasdale, Kolpakchi, & Skelly, 1993; Reamy, Kim, Zarit, & Whitlatch, 2011). Individuals may also express values regarding relationships, care, health, avoiding being a burden, finances, and safety/security (McCullough et al., 1993; Reamy et al., 2011). Preferences for such values in PCC are expected to inform care.

Existing Theories for Understanding How Preferences Influence Care and Care Outcomes

Lacking in the literature is a theory for how preferences as expressions of needs, values, and goals, once integrated into care affect psychological well-being among LTSS recipients. In the absence of such a framework, we turn to existing theories of human motivation and aging which we integrate to create a Preference-Based Model of Care. We focus our discussion on tenets from five key theories: (a) Theory of Human Motivation, (b) Self-determination Theory (SDT), (c) Person–Environment (P–E) Fit: The Competence-Press Model (CPM), (d) Living Systems Framework, and (e) Broaden-and-Build Theory of Positive Emotion: Affect Balance. We consider the key assertions of each theory and the relationship of concepts to outcomes of psychological well-being (Table 2).

Table 2.

Overview of Existing Key Theories and How they Inform the Development of the Preference-Based Model of Care

	A Theory of Human Motivation	Self-determination Theory	Competence-Press Model	Living Systems Framework	Theory of Positive Emotion
Key assertions	All humans have a basic set of hierarchical needs that drive goal-directed behavior. These needs include: physiological, safety, belongingness and love, esteem, and self-actualization. Humans are consciously and unconsciously motivated to meet these goals in order to gain self-fulfillment. Needs do not occur in isolation.	People are intrinsically motivated toward personal growth when their environment is supportive and their psychological needs are met; specifically, their need for autonomy, competence, and relatedness.	There is a transaction between a person’s level of competence and the level of environmental press (e.g., environmental demand).	Expressions of needs are conceptualized in terms of goal-directed “behavior episodes”; when people attempt to achieve a need/goal, they decide what to accomplish (directive), how to do it (control), act based on plan (transactional), observe and evaluate the success or failure of plan (monitoring) and readjust plan as needed (regulatory).	A person has a daily ratio of positive to negative emotions (e.g., affect balance); optimal level of affect balance is to have more positive emotions each day.
Role in Preference-Based Model of Care	Psychosocial preferences are indicators of an individual’s physiological and psychological needs.	Psychosocial preferences are expressions of how a person fulfills their needs for autonomy, competence, and relatedness.	Outlines how a person’s well-being is impacted by environment; provides social, cultural, and political context to the interactions between the person, their environment, and related outcomes.	Goal-directed behavior episodes are the actions a person takes to fulfill preferences; people are active in fulfilling their needs (e.g., preferences); preference fulfillment results in positive outcomes (e.g., affect).	Affect balance and well-being are outcomes essential to understanding how and if a person’s preferences have been fulfilled.
Relationship to outcomes	A positive outcome is reflected by satisfied people who demonstrate positive affect; negative outcomes result in unsatisfied people resulting in neurotic behaviors or negative affect.	Positive outcomes (e.g., well-being) result when a person’s needs are fulfilled and supported by their environment; negative outcomes (e.g., ill-being) result when a person’s needs are not fulfilled or supported by their environment.	Positive outcomes (e.g., well-being) result when there is a person–environment fit (i.e., balance between competence and press); negative outcomes (e.g., ill-being) result when there is a lack of fit.	Positive outcomes (e.g., positive affect) result post-behavior episode when goal achieved and needs are met; negative outcomes (e.g., negative affect) result post behavior episode when goals not achieved or needs are not met.	Positive outcomes (e.g., well-being) result when a person’s affect balance has a higher positivity ratio; negative outcomes (e.g., ill-being) result when a higher negativity ratio.

Theory of Human Motivation

Maslow’s (1943) Theory of Human Motivation is foundational in describing how the basic needs of a person are manifested into psychosocial preferences. Maslow asserts that humans have a basic set of hierarchical needs that drive goal-directed behavior: physiological, safety, love, esteem, and self-actualization. Physiological needs are the starting point for the Theory of Human Motivation and represent the body’s natural effort to maintain homeostasis as an organism where the body is intrinsically balancing elements such as water, oxygen, vitamins, and minerals. A lacking in any bodily element triggers a strong motivational desire to consume food, or partake in other behaviors, that will replace the missing element. Using appetite as an example, Maslow argues that a person’s food preferences are an accurate representation of the missing bodily element effectively guiding conscious and unconscious behaviors towards satisfying the basic physiological need. When a person satisfies their physiological needs, they move to the next need in the hierarchy centering their behavior around satisfying that need. If all needs are satisfied the person reaches a sense of gratification (Maslow, 1943).

Maslow’s foundational theory of needs sets the stage for better understanding the mechanisms by which preferences affect outcomes. It specifically situates preferences as expressions of needs. As a part of the process in moving through the hierarchy of needs, a person’s psychosocial preferences as representations of basic human needs are pivotal in reaching positive psychological well-being. However, this theory does not take the next step of proposing how adherence to preferences results in positive well-being in a context of care.

Self-Determination Theory

Deci and Ryan’s (2000) SDT build’s on Maslow’s theory and highlights how individuals’ actions are driven by a sense of intrinsic motivation and tendency toward growth. According to Deci and Ryan (2000) individuals are intrinsically motivated to fulfill three psychological needs: (a) autonomy, (b) competence, and (c) relatedness. Autonomy is a person’s need to feel control over him/herself, his/her actions, and goals. Competence is the need for a person to feel productive and to have a sense of mastery over actions and goals. Relatedness is the need for a person to feel as if he/she belongs and thrives with others. Deci and Ryan (2000) specify how intrinsic motivation to achieve these needs is related to personal growth: (a) when able to do so, people proactively fulfill their needs, (b) growth is inherent to all people, despite their unique backgrounds, and (c) growth requires action from the person. Extrinsic motivation is addressed in SDT by indicating that internalization of external attributes into one’s value systems will produce growth. For example, the internalization of social norms into sense of self will promote well-being. Ultimately, individuals grow when their psychological needs are met; conditions (i.e., environment) that support the fulfillment of these needs promote well-being, whereas conditions that thwart need fulfillment compromise well-being (Deci & Ryan, 2000). When the environment prohibits individuals from fulfilling their most basic needs, their growth may be hindered and negative outcomes such as ill-being may follow (Deci & Ryan, 2000).

The SDT is integral for understanding preference-based care for three reasons: (a) the SDT supports the foundation that preferences are an expression of psychological needs; (b) the SDT supports the notion that individuals are proactive in fulfilling their needs; and (c) the SDT links the fulfillment of needs and the influence of the environment to individuals’ affective well-being. However, again this theory lacks a development of how care for older adults that meets preferences results in psychological well-being.

P–E Fit: The CPM

Along the lines of environmental influence, Lawton and Nahemow’s (1973) general ecological model of aging, commonly referred to as the CPM informs our understanding of how actions, based on individual motivation within a context, can influence well-being. Lawton and Nahemow (1973) model P–E fit as a function of ongoing transactions between the aging individual (i.e., changing level of competence) and the level of environmental press (i.e., demands and challenges an environment presents for its inhabitants). They hypothesize that individuals with low levels of competence—for example, people living with advanced dementia—will tend to be more sensitive to small changes in environmental press than those with higher levels of competence (i.e., the “environmental docility” hypothesis). According to the CPM, there is an optimal range for the ratio of personal competence to environmental press. Too much or too little environmental press at a given level of competence results in negative affect and maladaptive behavior (Lawton & Nahemow, 1973).

In the years since the CPM was introduced, gerontologists have built on this model to improve understanding of the person defined in the environment and the meaning of competence. Lawton (1989) expanded the original conceptualization of person to include personal resources in addition to competence. Rubinstein and de Medeiros (2003) further integrated self, meaning, and embodiment as crucial elements in the model for understanding the culturally mediated transactions between an individual and his/her environment. Thus, the person in CPM is more than his/her capacity and ability to adapt to an external environment; a person is a culturally embedded, embodied self who plays an active role in P–E transactions. Furthermore, functional, cognitive, and affective ability as well as personality, are proposed to fluctuate in influence and importance based on environmental context (Wahl, Iwarsson, & Oswald, 2012), meaning that individuals draw upon personal and environmental resources in different ways at different times. Individual-level characteristics—including age and other demographic characteristics, personal history, social and cultural capital, emotional reserve, personality, and preferences—define the dynamic person in P–E fit. In regard to competence, Lawton (1989) advanced the “environmental proactivity” hypothesis which indicates with increasing levels of competence; individuals play an increasingly active role in shaping the environment to better meet their needs (Scheidt & Norris-Baker, 2003).

The CPM builds on the Theory of Human Motivation and SDT to provide key insights into how preference-based care can affect individuals’ well-being. The CPM and SDT both assert that an individual’s well-being is affected by the interactions between the individual and environment and recognizes the influence of the individual in actively shaping the environment to meet one’s needs (Table 2). The CPM adds additional insight by defining the roles of competence, personal attributes, and the overall context of the environment (e.g., social, cultural, political). Yet, still missing is the extension of this theory to the mechanisms by which preference-based care influences well-being.

Living Systems Framework

The fourth theory of interest is Ford’s (1987) Living Systems Framework (LSF) which offers a systematic account of the person-in-context as self-regulatory and adaptive. In this framework, human agency is conceptualized in terms of goal-directed “behavior episodes,” which involve a series of five interrelated processes: directive, control, transactional, monitoring, and regulatory functions. When a person is attempting to achieve a need or a goal (i.e., acting in accordance with a preference), he/she makes a decision of what to accomplish (directive), considers how to do it (control), acts upon such plans (transactional), then observes and evaluates the success or failure of the behavioral episode (monitoring) and may or may not readjust behaviors (regulatory). All of these functions cooperate to construct adaptive patterns of behavior that can serve different goals in different contexts. Regardless of functional ability or competence the same basic processes guide adaptation and development. In Ford’s framework, affect provides valuable information for self-regulation of behavior (i.e., positive affect, increases desire for repetition) and guides caregivers who are involved in creating a PCC plan who seek to enhance an older adult’s quality of life. A successful behavior episode produces satisfaction and pleasure and minimizes negative emotional outcomes.

The LSF builds on the other theories’ assertions of how preferences can influence individuals’ well-being. Similarly, the LSF assumes that individuals are active in fulfilling their needs. Importantly, the goal-directed behavior episodes are used to operationalize the actions individuals take to fulfill their preferences. The goal-directed behavior episodes thus serve as a mechanism for understanding how to meet individuals’ needs. The LSF also aligns with the CPM and SDT with its emphasis on affect as an outcome. However, while this theory is closest yet to articulating how when preferences (goals) are met the result is a positive impact on well-being, it does not directly link needs, preferences, and psychological well-being.

Broaden-and-Build Theory of Positive Emotion

A final theory that contributes to our understanding of preference-based PCC is Fredrickson’s (1998) Broaden-and-Build Theory of positive emotions. According to Broaden-and-Build Theory, one possesses an affect balance or a ratio of positive to negative emotions experienced on a day-to-day basis where the goal is to experience more positive than negative. The benefits of experiencing a relatively high ratio of positive to negative emotions (i.e., an optimal affect balance) accumulate over time. As individuals build up resources for coping with everyday stressors and add to their emotional reserve, they develop greater resilience in the face of adverse experiences (Fredrickson, 2001). A wealth of empirical evidence has emerged in support of Fredrickson’s (1998) theory (e.g., Cohn et al., 2009; Lyubomirsky, King, & Diener, 2005). Specifically, research has examined the association between affect balance and well-being among community-dwelling elders and nursing home residents and found that older adults with high well-being reported higher positivity ratios (Kolanowski et al., 2014; Meeks et al., 2012). These studies provide support for affect balance as an important target for PCC intervention focused on preference fulfillment.

In the model we propose next, the Broaden-and-Build theory completes the metaphorical puzzle. Fredrickson’s theory builds on the assertions of the other theories related to affect and the potential to use affect as a tool to assess individuals’ well-being, but takes it one step further and posits that the more positive emotions one has, the higher one’s sense of well-being will be. Assessment of well-being is crucial in understanding the impact of preference-based care.

A Preference-Based Model of Care

Drawing on the Theory of Human Motivation, SDT, the CPM, the LSF, and the Broaden-and-Build Theory, we propose next a Preference-Based Model of Care to articulate the mechanisms by which preferences affect care outcomes. We highlight why each theory is integral to the Preference-Based Model of Care and emphasize how the theories work harmoniously to create a guiding framework for how preference-based care affects the well-being of older adults. Table 2 summarizes the role of each theory in model construction.

In the Preference-Based Model of Care, preferences are the essence of PCC. Figure 2 provides a pictorial representation of the mechanisms by which preferences inform care delivery. At the center of the diagram is the older person and his/her needs. Each older person possesses the hierarchical needs outlined by the Theory of Human Motivation (Maslow, 1943) and psychological needs of SDT (Deci & Ryan, 2000). Needs are transformed by individuals consciously or subconsciously into values, goals, and preferences that guide how individuals want to have their needs met. The resultant preferences or goals then serve as the driving force behind behavior (i.e., processes outlined by Living Systems Framework; Ford, 1987). Preferences facilitate a person’s behavior or engagement in activities that meet his/her goals and needs. With a preference in mind, a person plans how to meet that preference (control function), acts to meet the preference (transactional function), monitors outcomes to see if the preference has been met (monitoring function), and adjusts behaviors accordingly (regulatory function). In the context of older adulthood when competence diminishes (i.e., physical or cognitive), as specified by CPM, the social and instrumental support from others and one’s environment become pivotal in supporting adherence to preference-based behaviors.

Figure 2.

The Preference-Based Model of Care.

As each theory outlines, when needs are met in ways that align with individuals’ values and goals (i.e., preference-based), individuals maximize growth and functioning. Affect balance (i.e., Fredrickson, 1998) is then a key outcome of individuals’ behaviors and a source of informational feedback guiding subsequent behaviors. A greater positivity ratio will encourage repetition of initial preferences and actions. The degree of fit between preference-guided behaviors and the environmental press (i.e., CPM; Lawton & Nahemow, 1973) also acts to produce a more or less favorable balance of positive and negative affect. A favorable balance reinforces the preferences in question, whereas an unfavorable balance induces reevaluation of preferences. These processes are embedded within a particular social, cultural, and historic context, meaning that individuals’ expressions of preferences may shift as the social environment or contextual circumstances change. And, although the model in Figure 2 is two-dimensional, the associations and causal mechanisms depicted are dynamic over time and across each individual’s life course.

To illustrate this model, consider the following example; Sally is 90 years old and resides in a nursing home. She formerly lived independently for 40 years in her own home but has moved to the residential care community after a fall. She experiences limitations in physical functioning including decreased ambulatory ability (uses a walker) and incontinence. Sally possesses the five hierarchical needs of physiological need, safety, love, esteem, and self-actualization. She also has psychological needs for autonomy, relatedness, and competence. Drawing on her past experiences, personality, and sense of self, she possesses a value system that ranks independence/autonomy and privacy as key values for her functioning. She possesses goals in care that align her needs within her value system to produce a set of desired behaviors that are achieved through the expression and fulfillment of her preferences for everyday living. Sally has a physiological need to be bathed regularly, especially given her experience with incontinence. She values privacy in addressing this need and therefore has the goal of washing in private. Her preference becomes expressed as a desire to wash herself every morning in her own bathroom, with an aid nearby to assist if needed (her directive and control behaviors). Because of her ambulatory restrictions, a care team is needed to support this goal (her transactional behavior). Sally will then experience success or failure for the activity and evaluate if it met her needs for cleanliness as well as her psychological needs for autonomy and competence to complete the washing as independently as possible (monitoring behavior). The adherence of a care team to her preference for a morning washing will maximize her experience of positive affect and set expectations for future bathing encounters (regulatory). Active engagement in her preferred activity will motivate her to repeat such actions because she finds them pleasurable and rewarding. The development of a care plan for her that accounts for this personalized preference creates a behavioral cycle for her that will result in improved well-being.

More specifically, Sally’s attributes, including physical, functional, cognitive, and emotional capacity, as well as developmental history and personality (Diehl & Willis, 2003; Lawton, 1989; Rubinstein & de Medeiros, 2003; Wahl et al., 2012) interact with the environmental circumstances to create an individualized goal-directed behavior. A person receiving care is culturally embedded and environmentally proactive, with a unique personal history that offers care providers a rich, if often underutilized, resource. Here Sally’s past experiences have shaped her value system that informs her behavioral episodes that seek to maximize well-being. The current care environment may further shape Sally’s current needs and how Sally expresses her preferences. Environmental proactivity and P–E fit both depend on Sally’s history of adaptive learning and active meaning-making (Ford & Ford, 2013; Rubinstein & de Medeiros, 2003). By honoring Sally’s personal history and current preferences, care providers can enhance opportunities for self-determined behavior while promoting psychological need fulfillment and affect balance. SDT (Deci & Ryan, 2000) posits that autonomy, competence, and relatedness are universal needs but there are individual and cultural differences in the meaning and relative salience of these needs, which suggests that there is no one-size-fits-all approach to need fulfillment. Interventions aimed at eliciting individual preferences care can help to facilitate environmentally proactive behavior and improve affective outcomes by permitting expression of these individual and cultural differences, rather than imposing a standardized plan of care.

The integration of prior theories thus, demonstrates the mechanisms by which preference-driven behaviors result in greater well-being. In applying this to the context of PCC in LTSS, scholars and practitioners can begin to understand that provision of preference congruent care (i.e., when an activity/behavior matches—or is congruent—in content and form with the given preference of an individual in a care environment) allows individuals to experience a greater affective positivity ratio (greater well-being).

Conclusions and Future Directions

This manuscript integrates theories from multiple disciplines to enumerate where preferences fit in the sequence of providing PCC and includes an emphasis on an outcome, positive affective well-being, that can be assessed for older adults receiving LTSS regardless of functional or cognitive abilities. Like any theory, the presented model must undergo rigorous testing and is subject to further refinement. For example, future research might explore the concept of behavioral balance—provisionally defined as engaging in a positive manner more often than an agitated/upset manner—when considering person-centered dementia care. Furthermore, this model was developed to address care for older individuals receiving LTSS, additional work will be needed to test this theory for its relevance in populations outside of LTSS (i.e., younger adults living in dependent care environments; hospitals). Yet, as presented, this model will allow researchers to formulate and test initial hypotheses regarding the mechanisms through which preference-based care affects psychological outcomes for older adults receiving LTSS. Findings from this work can inform practice guidelines and ultimately improve the delivery of PCC within LTSS.

Funding

This work was made possible in part by funding from The Patrick and Catherine Weldon Donaghue Medical Research Foundation and Award number R21NR011334 from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research, the National Institutes of Health, or the Donaghue Foundation.

Conflict of Interest

None reported.