People as Partners in Integrated Care: Exploring Pain and Systemic Barriers in an Aging Population

Background: The aging population in the United States often faces fragmented, inequitable healthcare, with older Black adults disproportionally experiencing undertreated pain with limited access to culturally competent care integrated services. This case study highlights the lived experience of an 89-year-old Black woman with multiple chronic conditions, highlighting the gaps in pain management and healthcare system barriers in the absence of behavioral healthcare.

 

Approach: A qualitative case study approach explores both the physical and emotional experience of an 89-year-old African American woman through observations, self-reported pain assessments, and caregivers’ interviews. Standardized tools, including pain scales, were used in conjunction with consideration of healthcare communication and digital record access within the context of person-centered and integrated care delivery.

 

Results: The patient experienced persistent pain, impaired mobility, and psychological distress, with her daughter carrying the burden of care coordination. The absence of community-based care further isolated the patient and her caregiver, limiting access to localized support networks and culturally aligned health resources. Noted barriers to a patient-centered approach include data protection policies and structural inequities driven by implicit bias. These gaps undermine the values of person-centered care, caregiver inclusion, and coordinated service delivery.

 

Implications: This case highlights the urgent need for patient-centered, and culturally competent models of care for older adults with multiple comorbidities as it is usually absent rather than integrated. The inclusion of behavioral health clinicians who adopt standardized screening tools (e.g., PASS-20) and create accessible EHR systems would reduce disparities and enhance the quality of life in aging populations.