AGES (Assessing, Guiding, and Empowering Seniors): An Aging in Place Initiative

Program Description

In 2014, The Bridge recognized that the complex needs of its senior residents with behavioral health diagnoses were outpacing its capacity to provide individualized services. We began our ‘AGES’ program with a Director of Aging Services and a Residential Nurse with the goal of helping Bridge tenants to manage their age-related health challenges and age in place. Our innovative model utilizes enhanced engagement, assessment and monitoring protocols to link older residents with co-morbid chronic behavioral and physical health disorders to community-based services. In 2016, we added a Case Manager, Peer Specialist and two social work interns to the AGES Team. The Team performs comprehensive assessments on Bridge residents ages 50+ to determine their community support and health care needs. This approach assists residents to stay in their homes longer and avoid costly, unnecessary hospital and institutional care. The Project also improves seniors’ quality of life by helping them to stay connected with their treatment providers and the community, decrease time spent away from home in medicalized settings, increase social connectedness and understanding of the aging process, preserve the highest level of autonomy possible, and identify opportunities for personal growth and wellness.

Creativity

AGES (Assessing, Guiding and Empowering Seniors) uniquely assembles a multidisciplinary team of professionals who possess expert knowledge of both aging and behavioral health in the care of older adults with complex needs. We were one of the first agencies to identify a need for integrated service delivery and have been resourceful in combining multiple competitive funding streams to support the program and fill a gap in the healthcare field for seniors with serious behavioral health disorders. Our model targets adults ages 50+ whereas many other programs only target seniors ages 62 and above. To best meet the needs of this vulnerable population, AGES provides services to clients where they live and spend their time, and utilizes mobile technology to enhance client involvement through collaborative care planning. AGES uses tablet computers and smartphones to increase service integration and client safety through field-based, real-time access to client health information across multiple providers.

Leadership

AGES’ design and implementation is guided by Jeff Welch, RN and Ian Johnson, LCSW. The Team created a specialized Needs Assessment Form and Care Plan that are used to identify seniors at highest risk for displacement. These tools can be made available to other organizations interested in implementing our model along with the AGES’ Resource Guide on The Bridge’s website. The Team provides direct services, behavioral and medical health education and counseling to consumers and staff, and coordinates care ensuring that it is comprehensive and fully integrated. Ian’s credentials, an LCSW and certified field instructor, allows us to utilize student interns to augment service delivery. Our collaboration with Hunter School of Social Work is preparing new professionals to work in mental health for older adults. Staff has participated in presentations and panels on aging in place, death and dying, sex and sexuality among older adults, and clinical interventions with seniors.

Sustainability

AGES is a grant-funded initiative. We plan to sustain the program beyond the grant period by demonstrating the cost effectiveness of this approach to our city and state funders and Managed Care Organizations. We will negotiate value-based payment methodologies and reimbursement through Medicaid waiver services that can be provided in home environments, and demonstrate the value-added contributions this program makes to improve quality of life for seniors while lowering costs through decreased utilization of acute and chronic care. The Bridge has an existing partnership with the CUNY Hunter School of Social Work to provide specialized internship placements for MSW students who have an interest in working with older adults with serious behavioral health disorders. AGES trains a minimum of two social work students each year to prepare the field for the growing demand for behavioral health care workers in aging services.

Replicability

AGES is an outcomes-driven, community-based service model that integrates the siloed systems of medical, psychological and substance abuse care for older adults with complex needs and can be widely replicated. The composition of the AGES Team can be adapted to maximize efficiency and effectiveness within a cost-conscience budget. Approximately 33% of AGES’ social work interventions are performed by MSW students under the supervision of the LCSW, dramatically lowering the cost of the program. Through the use and/or adaptation of AGES’ forms and existing evidence-based measurement tools such as the Uniform Assessment (UAS-NY), and the PHQ9 and AUDIT-DAST 10 for mental health and substance use, organizations can identify at-risk seniors, expedite the assessment process, and monitor the program’s effectiveness.

Results/Outcomes

All Bridge residents ages 50+ were assessed using the Needs Assessment Form in 2015 and 2016. Data on these 400+ residents enabled AGES staff to identify and serve 255 of our most vulnerable seniors: 71 received nursing intervention, 61 received social service intervention, and 123 received both. Seniors were seen an average of seven times annually, with some receiving up to thirty hours of service by the RN and social worker. All residential staff receive training on health and aging in both case-by-case and formal settings. Agency-wide, The Bridge has experienced an increase in referrals to medical specialists and community-based services relevant for older populations and many older clients have demonstrated an increased understanding of their medical conditions. Through advocacy, outside home care services and meal delivery, environmental modifications, and staff education and training, we have successfully stabilized 78% of those residents who were identified as high-risk for displacement.