Seniors Count Symposium, Neighbors Care: Let’s Make It Happen! Promotes Livable Communities for Manchester’s Frail Elderly
Seniors Count is a convener of partnerships that are a catalyst for community-based outreach and action to redefine and ensure independence for older people, and in doing so, create a better life for all. Seniors Count will partner with Catholic Medical Center, Elliott Senior Health Center, Dartmouth-Hitchcock Clinic, the Bureau of Elderly and Adult Services, the Manchester Department of Public Health, ServiceLink and the University of New Hampshire Institute on Disability to implement the Seniors Count Coordination Initiative.
This Initiative will create a seamless, person-centered care coordination model across the three areas of care most important to a frail senior; medical care, community living/social services, and caregiver support. The goal is to build a systematic way to effectively communicate the issues of frail seniors among these three areas of care which currently is challenging to navigate. The anticipated outcome is a replicable model to change “the face of aging” in communities throughout our country.
“The model will enable us to, for the first time, give the senior one point of contact when help is needed. It is through this model we will break the siloed approach to care provision for frail seniors and replace it with a coordinated effort across domains,” said Easter Seals President and CEO Larry Gammon. “We’d like to thank the Administration on Aging and all of the partners involved with this initiative in recognizing the key issues that prevent our frail seniors from aging their homes and communities and working collaboratively in addressing those issues.”
The biggest barrier frail seniors face in remaining in the community is not being able to adequately coordinate the complex array of services and issues that confront them. The community needs a renewed focus to create a plan that makes it possible for frail seniors to remain in the community by coordinating cross-agency communication addressing all aspects of aging personal, financial, and health.
“We are all responsible for making this happen, and this innovative model of care coordination ensures that we are at the same table formulating a strategy to best address the needs of our aging population,” said Paul S. Boynton, Moore Center President and CEO and chair of the Seniors Count Collaborating Council.
Nationwide, Seniors Count was one of only 14 programs selected to receive an Administration on Aging Community Innovations in Aging in Place grant.
“A grant of this magnitude will make an enormous impact on frail seniors,” said Seniors Count Project Director Arlene Kershaw. “It gives us the unique opportunity to create an innovative model of coordinated care for frail seniors.”
The grant is already underway with the establishment of a planning workgroup comprised of the Initiative partners. In addition to the planning workgroup, the Initiative will have an advisory committee consisting of members from the community including seniors, caregivers and other family members, advocates, community social service providers, gerontologists, mental health providers, political leaders and individuals representing the community health center, the faith-based community and the legal community.
“We look forward to partnering with this consortium of providers, social service, caregiver support and government agencies to improve the lives of our elderly and their ability to remain independently living in the community,” said Elliot Senior Health Director Malcolm Perry, LNHA, B.S. The Seniors Count Coordination Initiative will target a subset of frail seniors who are at great risk of failing to remain in the community. If deemed appropriate, the senior will then be given the option to participate. If the senior agrees to participate, a medical home will be established, if one does not already exist, and information about the senior, both medical and social, will be collected through assessments.
A Senior Care Plan will be developed with input from the senior and those community/social and medical providers and caregivers involved with the senior. The senior and the coordination team will identify a Seniors Count Coordinator. This individual will be the senior’s point-of-contact for as long as the senior is living in the community and will address the senior’s needs with the assistance of the appropriate team members or other community contacts.
This Initiative will allow all those involved in the senior’s care to share information. Because the Seniors Count Coordinator will see and/or be in contact with the senior more often than the medical providers will be, the Seniors Count Coordinator can alert the medical professionals about concerns that arise between medical appointments. These alerts will enable the medical providers to intervene earlier thereby averting premature nursing home placement or hospitalization.
This collaboration will also benefit the social service providers involved with the senior as they will have a more complete picture of the senior and will be better able to suggest services that will complement the medical services he/she is receiving, thus providing complete wrap-around service provision for the senior.
Most importantly, this collaboration amongst all those involved with the senior’s care will lead to the senior being able to remain in the community for as long as he/she wishes and is possible.