Innovations in Delivering Services to Older Adults

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Innovations in Delivering Services to Older
Adults

• Aryeh Sherman
• Jordan Golin
• Jewish Family Childrens Service of Pittsburgh
• May 2009

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• 1. Comprehensive Care Coordination
• A new approach to care management
• 2. Protective Factors for
• Maintaining Independence
• A research-based outcome measure

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What is Care Management/Coordination?

• Goal Coordinate available supports to keep
  Seniors in the community
• Individualized attention by social worker
• Assess needs as they change over time
• Connect with community resources
• Assist with coordination of medical needs
• Monitor financial, legal, social status
• Communicate with family as requested
• Phone, email, and on-site intervention

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Disadvantages of Standard Care Mgt

• Hourly fee
• Not covered by insurance
• Need for help ebbs and flows
• Difficult to prove need/impact
• Not a concrete service
• Confusing terminology
• Limited buy-in by client, family

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Elements of ComprehensiveCare Coordination
Package

• Assessment and Individualized Care Plan
• Monthly home visits by LCSW
• Monitor medical/emotional/financial/social/ legal
  status and help obtain resources
• Weekly reassurance calls
• Monthly family contact
• Biannual medication list review
• Quarterly newsletter
• Cognitive Enhancement program
• Keep-a-Key program
• Discount on other services (e.g. caregiver)

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Advantages of Comprehensive Care Coordination

• Fixed monthly fee
• Attractive package of services
• Ongoing communic. with family member
• Discounts on additional services
• Care plan sets parameters on services
• Regular contact ?less crisis work
• Measurable outcomes Protective Factors

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Protective Factors for Maintaining Independence

• Outcome measurement tool
• Research-based factors
• Focus on client strengths
• Correlated with nursing home admissions
• Adaptable to a variety of settings
• Easy to explain/understand

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Protective Factors

• Physical Health
• Psychological Health
• Social Relationships
• Safety Security

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Protective Factors

• Physical Health
• Age
• ADL Mastery
• Medical Coverage
• Medication Compliance
• Adequate Nutrition
• Exercise/Physical Activity

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Protective Factors

• 2. Psychological Health
• Emotional stability
• Cognitive intactness
• Sense of purpose
• Sense of control

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Protective Factors

• 3. Social Relationships
• Living with someone
• Social involvement
• Caregiver Functioning
• Health
• Stress
• Strain

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Protective Factors

• 4. Safety Security
• Income level
• Safe environment
• Appropriate housing
• Financial stability
• Maintains personal safety

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Contact Us

• Aryeh Sherman, Executive Director
• asherman_at_jfcspgh.org
• Jordan Golin, Clinical Director
• jgolin_at_jfcspgh.org
• [phone]