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Service Delivery Innovation Profile

Multiagency Collaborative Helps Community-Dwelling Seniors Access Coordinated Support Services, Helping Them Remain in Their Homes


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Snapshot

Summary

A partnership of three community-based organizations, AgeWell Pittsburgh provides a one-stop resource for community-dwelling older adults to learn about and access available resources to help them remain independent. It also proactively reaches out to these individuals to assess needs and connect them to coordinated services and support. The program has enhanced access to services for many older adults and has allowed the vast majority of frail older adults (those eligible for nursing home placement) to improve or at least maintain their scores on factors that determine the need for such placement.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of individuals served by the program; trends in scores on factors related to the ability to live independently; and anecdotal reports from program leaders.
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Developing Organizations

Jewish Association on Aging; Jewish Community Center of Greater Pittsburgh; Jewish Family & Children's Service of Pittsburgh; Jewish Federation of Greater Pittsburgh
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Use By Other Organizations

Partnerships in Baltimore, Cleveland, Philadelphia, and St. Louis also received grants for "natural occurring retirement communities" from the Administration on Aging; these partnerships have adopted some elements similar to the AgeWell Pittsburgh program, although they tend to rely more on creation of a natural occurring retirement community apartment building that provides a wide variety of onsite support services, rather than employing the multiagency service delivery model used in Pittsburgh.

Date First Implemented

2002
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Patient Population

The program serves those age 60 and older living in Allegheny County, PA.Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Although older adults typically want to live independently for as long as possible,1 they and their loved ones often remain unaware of or do not know how to access resources that can help them do so. Unable to take advantage of such services, they may decline physically and mentally, forcing placement in a nursing home or another long-term care setting.
  • Desire to live independently: Surveys have consistently shown that older adults prefer to continue living at home for as long as possible.1 The number of older adults wishing to remain in their own home will increase significantly in the future, as the population of adults age 65 and over is expected to double in the next 30 years.2
  • Limited access to resources that can help: Providing older adults with the right support services (e.g., health care, rehabilitation, support groups, transportation) at the right time helps them to remain independent and may prevent or delay unnecessary hospitalizations or placement in a nursing home or another long-term care facility.3 Yet most older adults and their loved ones remain unaware of resources that can help them stay in their homes. Even when they know of such services, they may find accessing them to be confusing and overwhelming.

What They Did

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Description of the Innovative Activity

A partnership of three community-based organizations, AgeWell Pittsburgh provides a one-stop resource to community-dwelling older adults to learn about and access available resources to help them remain independent, and also proactively reaches out to these individuals to regularly assess their needs and connect them to services and other support. Key program elements include the following:
  • Information and referral hotline: Anyone age 60 and over, or a family member, friend, or caregiver of that person, can call an information and referral hotline staffed during regular working hours by an information and referral specialist familiar with the service offerings of the three participating agencies and other community-based organizations. The specialist also understands how to elicit information from callers about their needs, and hence can make suggestions about needed services. The specialist typically gives the caller information about how to access suggested services, and often will contact the organization providing such services to give them the client's information and request that they proactively reach out to him/her. The information and referral specialist often follows up with the caller to find out if they pursued the needed services and to offer additional assistance. The hotline is promoted through the AgeWell Pittsburgh Web site (which also describes the various services of the partner agencies) and through periodic presentations, public relations, and targeted print advertising about the program.
  • Initial assessment using standard tool: Whenever any client seeks services for the first time at a partner agency (see the Context section for information on the services provided at each agency), staff within that organization use an internally developed tool known as Protective Factors for Maintaining Independence, which includes a series of questions to rate the client on a scale of 0 to 3 with respect to various factors that influence the ability to remain independent and avoid placement in a nursing home, including degree of cognitive impairment, whether the person lives alone, marital status, level of social support, level of physical activity, presence of depression, prescription drug use, income, ability to perform activities of daily living (ADLs), sense of purpose and control, and caregiver burden and well-being. Scores range from 0 to 3, with higher numbers signifying a greater ability to remain independent. This assessment helps to identify client needs and services to address them, including those offered by other partner agencies and community-based organizations. Staff have been trained to view client needs beyond their narrow area of expertise. As necessary, they will contact the information and referral specialist described above to learn about services that are unfamiliar to them which could assist the individual, and then pass this information on to the client.
  • Ongoing assessment at every encounter: Whenever any client seeks a service at any of the three collaborating agencies, service providers update the information in the Protective Factors for Maintaining Independence tool. Because staff and clients may have only limited time during any individual encounter, agency staff may focus only on certain aspects of the tool relevant to the service provided. If this "update" identifies new or ongoing needs that have not been addressed, the service provider will try to identify relevant programs or services to help. As with the initial assessment, the service provider will contact the information and referral specialist as needed to learn about such programs/services, and pass this information on to the client. For example, an exercise class instructor might notice a change in a client’s mood, and then refer that person to relevant programs offered by Jewish Family & Children’s Service, one of the partner agencies. In some cases, the provider may directly arrange for such services; see the Back Story section for an example where a service provider arranges transportation for a client.
  • Monthly assessments and proactive outreach using centralized database: All information gathered during individual encounters with a client feeds into a centralized database, which then serves as a single source for information from across the three partner agencies about which services a client has used and about his or her service needs going forward. Each month, service providers from the three partner agencies use this database to assess the needs of individual clients and to identify older adults at risk of losing their independence. Some AgeWell agency programs proactively reach out to these individuals by telephone to facilitate access to services that can help them avoid further physical and/or mental decline and the need for nursing home placement. The database also serves as an evaluative tool, allowing staff to document benefits for individual clients, such as cost savings, increased independence, and improved quality of life.
  • Volunteer program: Anyone served by a collaborating AgeWell Pittsburgh agency has the opportunity to "give back" to the community by volunteering in a program known as CheckMates. Volunteers support the AgeWell partners by following up with clients served through the network. For example, they make weekly phone calls to homebound clients to provide reassurance and determine if they need any assistance. If possible, they help to arrange for that assistance or contact AgeWell staff to alert them of the need to do so. Volunteers may also deliver meals to clients in their homes or serve lunch at a local senior center. (See the Back Story section for an example of how one volunteer worked with a client.)

Context of the Innovation

AgeWell Pittsburgh is a collaboration of 3 service delivery organizations—Jewish Family & Children’s Service of Pittsburgh, Jewish Community Center of Greater Pittsburgh, and Jewish Association on Aging; see bullets below for a brief description of agency services. The program developed in response to the struggles faced by older adults to find appropriate services to help them remain independent, and by frustrations among agency leaders about service overlap and competition among the three organizations, which tended to operate with little or no cross-agency collaboration. In 2002, agency leaders began to recognize the need to develop a more efficient, effective way to serve seniors in the Greater Pittsburgh area. Working with the Jewish Federation of Greater Pittsburgh, agency leaders applied for and received a grant from the Administration on Aging to create a "naturally occurring retirement community" or NORC in Allegheny County, PA, which has the second largest senior population of any county in the country (behind Dade County, FL).

The services offered by each of the partner agencies are briefly described below:
  • Jewish Family & Children’s Service provides care management services such as in-home visits, transportation, reassurance phone calls, service coordination, personal safety, in-home caregivers and in-home safety checks. The agency also offers psychological services such as mood and cognitive evaluation, medication management, and counseling.
  • Jewish Community Center of Pittsburgh offers socialization, recreation/exercise classes, and health and wellness programs, including classes in preventive health, nutrition education, stress management, and medication compliance.
  • Jewish Association on Aging provides comprehensive rehabilitation services at a Medicare-certified facility, including physical, occupational, speech/cognitive therapy, psychological, psychiatric, nursing, social, orthotic, prosthetic and physician services.

Did It Work?

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Results

The program has enhanced access to support services for many older adults, and has allowed the vast majority of frail seniors (those already eligible for nursing home placement) to improve or at least maintain their scores on factors that affect the ability to live independently.
  • Enhanced access to support services: AgeWell Pittsburgh annually serves 6,000 older adults and touches 10,000 lives through outreach and referral services. In the absence of this program, many of these individuals may not have been able to secure needed support, or would have faced significantly greater challenges in doing so.
  • Enhanced ability to remain independent, even among frail seniors: An internal review (from data collected by the tool described earlier) of 600 frail older adults (those eligible for nursing home placement) found that 18 percent showed improvements in scores on key factors related to the ability to remain independent, while another 73 percent showed no drop on such scores (which would have been expected in the absence of support from the program, as the ability to remain independent declines naturally with age). In other words, only 9 percent of those nursing home–eligible individuals served by the program showed any deterioration on these factors over the 12-month period.
  • Less duplication of services: Although this outcome has not been formally evaluated, program leaders report that the centralized database and information line have helped to reduce service duplication across agencies.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of individuals served by the program; trends in scores on factors related to the ability to live independently; and anecdotal reports from program leaders.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Hiring information and referral specialist: Program developers hired a full-time information and referral specialist to answer calls from older adults and their loved ones.
  • Creating centralized referral database: Program leaders developed a centralized database to facilitate interagency communication about client service needs.
  • Developing Web site to promote program identity: Program leaders created an AgeWell Web site to communicate the full breadth of services provided under the AgeWell umbrella.
  • Initial and ongoing training: Staff from the three agencies received initial training on the program's identity, values, and philosophy, including the need to take a broad view of client needs in the context of the larger AgeWell network. Program coordinators from the three participating agencies also lead monthly 1.5-hour training sessions that focus on educating staff on how to identify client needs and refer within and outside of the AgeWell network.
  • Monthly coordinator meetings: Program coordinators from each agency meet on a monthly basis to review the program and address any identified problems or opportunities.
  • Identifying and addressing service gaps: On an ongoing basis, program leaders look for any existing service gaps that might exist across agency offerings, and address them to the extent possible. For example, AgeWell began offering transportation services (funded jointly by the three partner agencies) after program leaders realized that many clients needed this service and existing community-based organizations did not provide it.

Resources Used and Skills Needed

  • Staffing: As noted, AgeWell employs one full-time information and referral specialist (a new position), and each partner organization designated an existing senior-level employee to serve as AgeWell program coordinator, with program-related functions performed as part of their regular job responsibilities. The 30 service providers (ranging from licensed clinical social workers to activity directors) who work at the three partner organizations participate in the program, including training sessions, as part of their regular responsibilities.
  • Costs: Data on total program costs are unavailable, as it is difficult to distinguish between AgeWell and individual agency expenses.
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Funding Sources

Administration on Aging; United Way of Allegheny County; Rita J. Gould; The Harry & Jeanette Weinberg Foundation, Inc.; Jewish Federation of Greater Pittsburgh; Jewish Healthcare Foundation
The program was initially supported by a federal demonstration grant from the Administration on Aging. In addition, the three partner agencies contribute money to cover the compensation for the one AgeWell full-time employee. Grant funds and agency in-kind contributions cover other activities to maintain the program (e.g., analyzing data from the AgeWell database).end fs

Adoption Considerations

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Getting Started with This Innovation

  • Seek funding to cover costs of agency collaborations: Using outside assistance, if necessary, identify and apply for external funding, which can provide the necessary incentive for agencies to pool resources to create an umbrella organization.
  • Secure senior leadership support: Secure a commitment from senior agency leaders to create the partnership by quantifying expected program benefits, including elimination of service duplication and the ability to keep older adults living independently for as long as possible.
  • Develop program identity: Discuss and agree on a common purpose, values, and philosophy, and then train and direct service staff from all partner agencies to carry out program services.

Sustaining This Innovation

  • Obtain and maintain buy-in from partner organizations: Leaders and staff within each partner agency must continue to believe in the program philosophy. Ongoing training on program values and goals can help to maintain such loyalty.
  • Share success stories and data documenting impact: Regularly share stories of older adults who have benefited from the program, along with quantitative data documenting the program's impact. Sharing such information with leaders, agency staff, and potential funders serves to keep all stakeholders motivated and engaged.
  • Maintain program identity: To maintain trust and a shared identify, conduct monthly training sessions for staff where they learn to view client needs within the larger network of resources (rather than having a single-agency perspective).
  • Identify and address service gaps: Continually monitor services available in the community to make sure that client needs are being met. To the extent possible, address identified gaps.

Use By Other Organizations

Partnerships in Baltimore, Cleveland, Philadelphia, and St. Louis also received grants for "natural occurring retirement communities" from the Administration on Aging; these partnerships have adopted some elements similar to the AgeWell Pittsburgh program, although they tend to rely more on creation of a natural occurring retirement community apartment building that provides a wide variety of onsite support services, rather than employing the multiagency service delivery model used in Pittsburgh.

More Information

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Contact the Innovator

Jordan Golin, PsyD
Director of Clinical Services
Jewish Family & Children's Service of Pittsburgh
Phone: (412) 422-7200
Fax: (412) 422-1162
E-mail: jgolin@jfcspgh.org

Alexis Winsten Mancuso
Assistant Executive Director
Jewish Community Center of Greater Pittsburgh
(412) 521-8010
E-mail: amancuso@jccpgh.org

Sharyn Rubin

Director of Resident Advocacy and Volunteer Services
Jewish Association on Aging
(412) 521-1171
E-mail: srubin@jaapgh.org

Innovator Disclosures

Dr. Golin, Ms. Mancuso, and Ms. Rubin have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The AgeWell Pittsburgh Web site is available at http://www.agewellpgh.org. The AgeWell Pittsburgh Information and Referral Number is (877) 243-1530 (toll free) or (412) 422-0400.

Jewish Family & Children's Service of Pittsburgh Web site is available at: http://www.jfcspgh.org.

The Jewish Association on Aging Web site is available at: http://www.jaapgh.org.

The Jewish Community Center of Greater Pittsburgh Web site is available at: http://www.jccpgh.org.

U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy "Supportive Services Programs in Naturally Occurring Retirement Communities." November 2004. Report available at: http://aspe.hhs.gov/daltcp/reports/NORCssp.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Bayer AH, Harper L. Fixing to Stay: A National Survey on Housing and Home Modification Issues. Washington, DC: AARP; May 2000.
2 Administration on Aging. A Profile of Older Americans 2002. August 2004. Available at: http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2002/2002profile.pdf.
3 Gibson MJ et al. Beyond 50.03: A Report to the Nation on Independent Living and Disability. Washington, DC: AARP; May 2004.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 14, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 01, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
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