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Building an Aging-Prepared Community: Lessons from an Ongoing Evolution (Session #36). NY SOFA Conference “Empowering Communities” November 13, 2008 Saratoga Springs, NY. What We'll Cover. Our community needs and our vision Our first foray: the Senior Information Center

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building an aging prepared community lessons from an ongoing evolution session 36

Building an Aging-Prepared Community:Lessons from an Ongoing Evolution (Session #36)

NY SOFA Conference

“Empowering Communities”

November 13, 2008

Saratoga Springs, NY

what we ll cover
What We'll Cover
  • Our community needs and our vision
  • Our first foray: the Senior Information Center
  • Social services delivery and lessons learned
  • Building social capital efforts and lessons learned
  • Preventive therapy and lessons learned/results
  • Current efforts
what we ll cover3
What We'll Cover














Takes Over












Takes Over



NNORC adds

Preventive Tpy


Care Advocate



seniors in the downtown communities what we know
Seniors in the Downtown Communities: What we Know
  • VOICES Longitudinal Survey
    • Rising depression symptoms
    • More chronic pain
    • Rising IADL assistance needed
    • "No one to turn to"
  • Village Nursing Home Admits
    • Falls and Accidents
    • Dementia
    • No safe discharge from hospital/ no


vision of reforming ltc
Vision of Reforming LTC

Frailty can be


or permanent.

Aim to


upstream with

early detection,

prevention and

wellness initiatives

nys ltc demonstration
NYS LTC Demonstration
  • Make growing old in the community a better proposition by :
    • Providing services and supports that are affordable, safe, and combine medical and non-medical interventions.
    • Building community capacity that supports diversion and transition
    • Enlisting “natural community contacts” as collaborators
  • Redirect and reinvest Medicaid savings toward home and community-based services.

“Everything that can be done in the community will be done in the community”

throwing the pebble opening the senior information center
"Throwing the Pebble": Opening the Senior Information Center
  • Responding to the need for "someone to turn to" when you have issues or


  • Opened May 2002
    • Brochures / Applications
    • Computer training and access
    • Social Worker in the window
computer classes and access
Computer Classes and Access
  • Seniors' Reaction
    • 20 – 25 attendees per computer class
    • Info Center daily visits climbed
      • June 2005: average 3/day
      • June 2006: average 18/day
  • Easy path to ask for help
    • Familiarity with Info Center staff
    • "Since I'm here . . ."
    • First year: 250 SCRIE applications
computer classes and access9
Computer Classes and Access

Among community-dwelling older adults, computer users reported significantly fewer depressive symptoms than their counterpartswho were not computer users.

They also had better perceived emotional support.

social services needs found
Social Services: Needs Found
  • Housing: landlord difficulties
  • Financial difficulties
  • Difficulty with chores / physical frailty
  • Feelings of isolation
  • Caregiver burden
  • Hoarding and home safety
  • Vision and hearing impairment
social service responses lightbulb team
Social Service Responses: Lightbulb Team
  • Volunteers available to assist with changing light bulbs and batteries
  • Able to enter home and perceive other needs
    • Hoarding
    • Physical frailty
  • Lessons Learned:
    • Clients receptive to home visits and community referrals
    • Volunteering interest declined over time
social service responses care advocacy
Social Service Responses: Care Advocacy
  • Facilitates care across time, place and discipline
  • Key collaborations with hospitals, nursing homes, CHHA, adult day, supportive housing, HCBS
  • Intent: nursing home diversions and transitions.
  • Role is part advocate, part systems-change-agent.
  • Tools to identify vulnerabilities and frailty
  • Patient tracking essential
  • Challenges: housing; reluctance to think outside the box/try something different (providers and patients)
care advocate case study
Care Advocate Case Study
  • SNF resident: cognitively intact with ambulation difficulty
  • CA and resident care planning:
    • Identified ongoing physical therapy program
    • Completed housing applications and tours
    • Facilitated transition communications
    • Provided informal counseling
  • CA facilitated move to Assisted Living and purchased some household necessities
  • Follow-up with AL Social Worker to ensure information and resident preferences are understood
social service evolution nnorc
Social Service Evolution: NNORC
  • Neighborhood NORC: Provide supportive services to a geographical area defined by density of seniors
  • "Heart of Greenwich Village"
    • 1,700 seniors over age 60
    • 50% live alone (compared to 28% nationally)
    • 30% live above first floor without an elevator
    • 29% meet criteria for depression
    • 51% report chronic pain
  • Provide social service assistance and added exercise classes and nursing
social service evolution nnorc continued
Social Service Evolution: NNORC continued
  • Biggest Value: Social services assistance with benefits, entitlements, linkages
  • Members also appreciate the ongoing education through monthly newsletter and quarterly publication
  • However: no interest in Nursing
    • Two "Ask-a-Nurse Days" and 1 attendee
    • Confusion as to why a nurse should visit them
    • NB: White, well-educated community with long-standing physician relationships
building social capital learning the model
Building Social Capital: Learning the Model
  • Research Base:
    • Kennedy School, Harvard University: social networks and the inclinations that arise from these networks to do things for each other
  • Existing Models Explored:
    • NORCs
    • Successful Aging in Caring Communities (Asset-Based Community Development Model)
    • NCOA's Civic Engagement Initiative
building social capital community building groups
Building Social Capital: Community-Building Groups
  • Advisory Group picked appealing efforts
  • Assigned a senior to "champion" each group
  • Staff member assigned to each group to facilitate relationship-building


"Out and About"

Greenwich Village Oral History Project

Walking for Fitness

School Support

Intergenerational Playwriting

Film Club

Helping Hands Group

building social capital reasons for failure
Building Social Capital: Reasons for Failure
  • The usual declining interest pattern
  • Ideas and champions all planned—nothing "organic"
  • Fears generated by mixing ages / abilities
  • Fear of finding the "excessively needy"
building social capital intergenerational issues
Building Social Capital: Intergenerational Issues
  • Seniors Dropped Out Because:
    • "Children not respectful"
    • "Didn't have enough energy to be with them"
    • "Those bigger kids are frightening"
    • One individual was requested to leave because grooming habits scared the children
  • Children Dropped Out Because:
    • "Didn't give us any say"
    • "Boring"
building social capital the merchant project
Building Social Capital: The Merchant Project
  • Originally, requests for member discounts
  • Trained merchants on how to be a "senior-friendly" establishment and why its good business
    • Window sticker to signal themselves to potential senior customers
  • Trained merchants to be "Eyes and Ears" to find and help seniors in need
merchant project case study
Merchant Project Case Study
  • Local ice cream shop owner who was trained to call APC with "seniors-of-concern"
  • APC Staff found Mrs. C and got consent for home assessment
  • Needs identified: nutritional services, cleaning services and financial management
  • Mrs. C now on: Meals on Wheels and APS for home care and financial management
merchant project evolution downtown gatekeeper program
Merchant Project Evolution: Downtown Gatekeeper Program
  • 2007 OMH/SOFA RFP
  • Village Care Merchant Project together with St. Vincent's Behavioral Health Assessment Program
  • Train merchants, building staff and others in the community to identify potentially mentally-ill seniors and refer them the "Gatekeeper Coordinator"
merchant project evolution downtown gatekeeper program continued
Merchant Project Evolution: Downtown Gatekeeper Program, continued
  • Gatekeeper Coordinator LMSW with mental health background
  • Reaches out to the identified senior and encourages formal mental health assessment
  • Makes appointment for –or walks the senior over to—St. Vincent's Behavioral Health
preventive therapy
Preventive Therapy
  • 2003 AoA RFA for Evidence-Based Prevention
  • Village Care builds on the Yale Center on Aging's "Prehabilitation Study.“
    • Identify seniors at-risk of functional decline with extra-simple screening tools
    • Provide "exercise prescription" to improve gait, balance and strength
  • Physical activity in the context of "therapy"
  • AoA team rejects, but AoA officials ask NYC DFTA to find funding
    • 2004, NY Community Trust funds one-year program replication
preventive therapy next steps
Preventive Therapy : Next Steps
  • NNORC exercise classes continue their popularity but can't sell the nursing so . . .
  • Convert NNORC nurse to Preventive Therapist
    • PT to provide exercise classes
    • PT to screen for risk
    • PT to do home assessment and exercise prescription
    • PT and NNORC support staff to do follow-up phone calls and home visits
where the apc stands now keeping what works best
Where the APC stands now: Keeping What Works Best
  • Senior Information Center
    • Computer access
    • Walk in information-and-referral
    • Social service assistance
      • In-home visits and supportive counseling for complex cases (folds in Care Advocacy)
  • Exercise Classes at Senior Center (and now Preventive Therapy)
  • Gatekeeper Program
where apc stands now staffing and partnerships
Where APC stands now: Staffing and Partnerships
  • APC — Senior Social Services – Director
  • BSW-towards-MSW NNORC Coordinator
  • MSW Gatekeeper Coordinator
  • BSW Senior Information Center
  • PT for Exercise Classes and Preventive Therapy
  • Partnerships: St. Vincent's Behavioral Health, St. Vincent's Senior Health, The Caring Community Meals-on-Wheels and Senior Centers,
where the apc stand now contact information
Where the APC stand now: Contact information

Renee Cottrell, Director of Senior Social Services

212 - 337 – 5897

Allison Nidetz and Allison Silvers

Senior Information Center

220 W. 26th St. NY, NY 10001

212 - 337 – 5900

Downtown Gatekeeper Program

212 - 337 - 5905