Successful Models of Community Long Term Care Services for the Elderly

Eloise H Killeffer, Ruth Bennett

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317736547
• Edition: 1
• Topic: Ciencias sociales
• Subtopic: Gerontología

Learn about the exciting possibilities for maintaining elderly residents in their own homes by marshalling available resources to pay for needed support services. Experienced practitioners provide examples of successful community-based long-term care service programs for the elderly, programs that are supported by a mix of public funds and private resources. They explore the role of service providers in developing successful models of community-based long-term care services--housing, home care services, comprehensive senior centers, and day care, among others--and discuss not only the successes of the particular programs but the obstacles and barriers that had to be overcome as well. Chapters focus on policies for the development of effective models, from the perspectives of municipal, county, state, and federal governments involved in community service provision, and the role of colleges and universities in training personnel to develop and implement community-based long term care services. Taken together, thistutorial, taught by practitioners who offer wisdom and insight based on their hands-on experience, is indeed a unique contribution to the field of long-term care.

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PART I:
SERVICE PROVIDERS’ ROLE IN DEVELOPING SUCCESSFUL MODELS OF COMMUNITY CARE

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Introduction to Part I

The range of services provided to the elderly in the community is very broad, although the elderly are not mandated to use these services and often, even if they need them, will not have heard about them. Thus, the best advertisement for an organization or agency providing these services to the elderly in the community is a satisfied client.

The agencies described in this section have exceptionally good reputations in New York City and its environs. From them, students in the Division of Geriatrics and Gerontology are able to learn about state-of-the-art or best practices in administration and service delivery to the elderly in the community. These agencies have been around for some time and have experienced many of the hurdles and problems well-known throughout the field of community-based service delivery. The authors of the presentations below share some of the “tips” they have found useful in order to survive and flourish.

In addition, several of the authors discuss problems that have not been addressed to their satisfaction; it was profitable to conference attenders to have these issues aired.

Ellen Camerieri’s chapter introduces this section on “Service Providers’ Role in Developing Successful Models of Community Care.” In her presentation on “Comprehensive Community Centers,” she notes that senior centers are the easiest service for an elderly person to access because there are no eligibility criteria to satisfy other than age and city of residence. Once in such a center, the elderly person is made aware of most of the other services available to the elderly. Thus, ideally, the senior center is at the hub of the wheel of services that may be needed ultimately. Were there a community-based system in place, the senior center might be the perfect entry point into the system. Unfortunately, many elderly people do not become members of senior centers for all sorts of reasons. Therefore, they may remain uninformed about other services that are available until they reach a point of serious need. Under the best circumstances, it would be beneficial for all elderly to join senior centers, where they can not only learn about other services, but can socialize, engage in all kinds of activities, pursue all sorts of interests and participate in health promotion and illness prevention projects.

George Kaplan describes the New York City Home Attendant Program administered by the Jewish Association for Services for the Aged (JASA). In this chapter, he refers to the Extended In-Home Services for the Elderly Program (EISEP), which provides services to elderly persons just above the Medicaid level. He notes some of the problems encountered in administering this program. Lois Grau raises some problems in her discussion of “Home Care Services: Non-Professional Home Attendants.”

Ralph Hall, in his chapter on “Day Care and the Continuum of Care,” describes an adult day care program that is part of a major nursing home. The theme of nursing home-based community care is also addressed by Theresa Martico-Greenfield in “Nursing Home-Based Community Care.” Institutions often are in a good position to share their resources with elderly persons who reside in the community. Thus, each nursing home can become a self-contained long term care system if it provides the full range of services along the continuum of care.

Igal Jellinek addresses the day-to-day problems encountered by community-based agencies trying the serve the elderly in an efficient and effective manner. Sometimes, this job can be accomplished only by coalescing with other agencies trying to serve the same population. His chapter on “Coalitions” discusses these and other related issues.

Douglas Holmes describes his research on “Special Populations” who may be underserved because of the lack of a true long term care system in any given community, city or state.

David Wilder describes his research on unmet needs of the community-based elderly. His chapter on “Filling the Housing and Service Gap” seems an appropriate way to end this section. Clearly, the community-based long term care system is in an embryonic stage — or, perhaps, in its infancy. All needs of all elderly people are not as yet being met. However, good starts have been made.

Comprehensive Senior Centers

Ellen Camerieri, CSW

Located in the Bronx, Riverdale Senior Services is a community-based multi-service program for the aging, like many others around the state and around the country. It is, for many older people, their first point of contact with the system, with the aging network—whatever it is called and whatever model is being used. Why would a center be the first point of contact? Primarily, because there is no assessment tool. A person must be sixty and live in New York City — it’s that simple. He/she just walks in—if he/she likes it, he/she takes it; if he/she doesn’t, he/she leaves. Nobody decides whether he/she is entitled to membership or not. In a sense, therefore, it’s the most universally accessed form of service.

What are some of the distinguishing characteristics of a comprehensive senior center? “Center” here implies a much more total package than a meal and one activity a day. It is also much more than a nutrition site: rather, it is a full-service package. People come into a center at any point in the aging continuum. Riverdale Senior Services has members from sixty to ninety-six; indeed, there are more than a hundred people over ninety on the membership rolls, although not all of them currently come to the center. Recently, the center signed up a ninety-six-year-old gentleman who just walked in and decided that he may have reached the age at which the center might be of some service to him. Thus, the senior center is a very democratic agency. It touches people not only in different stages of aging but also at different levels of need. One could be sixty and in great need of medical and social services. Alternatively, one could be ninety-six and just want to join and participate in only one or two activities. Thus, there is a very wide variety of choice.

If the senior center is really part of the total aging services network, it is because it has developed strong linkages to the community. Riverdale Senior Services is very fortunate because its board is a part of the local community. In many ways, Riverdale is more of a small town than a New York City neighborhood, in the sense that most people think of New York City neighborhoods; and the board is local, committed and talented. The agency grew out of a perceived need in the community and was tailored over the years to meet the changing needs that have been expressed within the community.

Riverdale Senior Services has many points of contact with the larger service system, the more formalized aging network. First is strong contacts with metropolitan New York Schools. Students from Columbia University’s Schools of Public Health and Dentistry and the Programs in Occupational Therapy pursue geriatric specializations through placements at the center. Student nurses from Mt. St. Vincent College receive team training with community elderly. This exposure helps combat the sick role myths about the elderly, for the students see that not all elderly are so deteriorated that they must be institutionalized, in either hospitals or nursing homes. Indeed, many of the people who are coming to centers today would have been in institutions in prior years.

What does this say for today’s senior centers? It says that they have to do an incredible stretch to serve recent retirees who are just looking for a way to maintain their ego identities with some useful, meaningful involvement, as well as the growing numbers of frail elderly, the newly-widowed, and the almost-infirm and, in some cases, even Alzheimer’s patients. Many elderly coming to the center need more care than we can offer, but if they had not come to the senior center, they would not later be referred to the services and programs they need. Thus, senior centers have to know all the resources and have good connections with them. They must not be proprietary; they must want to get elderly people to the services that will benefit them, which is not always where we would like to have them.

Riverdale Senior Services cooperates with many of the resources in New York City, such as the Hunter-Brookdale program which provides trained Medicare volunteers. This is necessary because many Medicare recipients simply pile up bills and never seek reimbursement, because it is all just too confusing. Even when a statement says “this is not a bill,” many elderly pay it anyway. Trained volunteers are invaluable resources in this regard. The social worker at Riverdale Senior Services facilitates Medicaid applications for elderly attenders. Trained by the New York City Department of Social Services, she is authorized to pre-certify, thus easing the initial stages of entry into that system. Final certification must be done at the Social Services Office, however. These are all very acceptable and useful services for recent retirees who want to continue to do something, who want to be affiliated with the aging network—but not too affiliated, because they’re not too aged yet.

All of the services provided by Riverdale Senior Services stretch a very small staff, even though the center is considered to have a good staffing model: a director who is a social worker; an assistant director, also a social worker, who does the social service supervision and the student supervision; and a program director who puts together a package that goes from art to yoga, and that includes many volunteers. Many members themselves are volunteers: e.g., a seventy-five-year-old yoga instructor who appeared in the River-dale Press standing on his head. Riverdale Senior Services has wonderful resources, and it tries to capitalize on them. But there are two hundred people a day on the premises. Visitors from nursing homes have inquired about the staffing patterns, and they are amazed to learn that it consists mostly of preprofessionals and support staff. This minimal staffing has one advantage, however: it compels the center to draw upon the people themselves and their relatives and friends and to turn to the community for support.

However, the concept of multi-service senior centers has gone just about as far as it is going to go without additional overhead resources. New service packages are made available offering money, e.g., for transportation of volunteers, but without allowance for more staffing; and centers are expected to run this little transportation program for a thousand people. Or, an Alzheimer’s respite program may be offered, but with staff only one day a week. Riverdale Senior Services rarely declines such opportunities, but finding funds to participate in these programs is increasingly difficult. So it is that multi-service senior centers must demand adequate funding to support the variety of programs needed to serve their members appropriately and well. Senior centers also have to fight to retain those characteristics that have made aging services so gratifying over the years — the mix of people: the ethnic mix, the income mix, the age mix. While increased professionalization is laudable, increased bureaucratization is deplorable. Is a twenty-page EISEP assessment tool really necessary for somebody who needs four or eight or twelve hours of home care a week? Is the overhead incurred in centralizing something like this justified? Is the machinery going to outpace the service? There is no easy answer to this one, because things cannot be done the way they used to be, in terms of the numbers, the needs, the increased lifespan, and not just the increased numbers, but the increased frailty. But the EISEP partnership has got to be more than just a paper partnership; what is occurring with the area agency in this area is much more of a paper than a real partnership. This could be extremely destructive if it does not change. Although this may be viewed, generally speaking, as resistance to change or intransigence, perhaps it is just a different perception of what the needs are and how they can be met. There must be a marriage, and there must be a dialogue. Opportunities such as this conference give us some hope for a happy marriage.

New York City Home Attendant Program

George Kaplan

The Jewish Association for Services for the Aged (JASA), based in New York City and covering Nassau and Suffolk counties as well, is a multi-purpose social service agency and an affiliate of the Federation of Jewish Philanthropies. JASA provides a variety of services, including case work, group work, housing, legal services, nutrition and transportation. Another service offered by JASA is home care, provided through three subsidiary corporations with two contracts, one from the Human Resources Administration and one from the New York City Department for the Aging. This is the new EISEP: Expanded In-Home Services for the Elderly Program. This presentation concerns the home attendant program, JASA’s role in it and some of their experiences with it.

EISEP evolved from a rather informal housekeeping/homemaking program, based at Montefiore Hospital, that existed even before Medicaid. In the early 1970s, Medicaid began paying for these services, but it soon became apparent that exceptions to their existing policies were becoming necessary more and more frequently. That is, many elderly people (e.g., those just discharged from hospitals) needed more housekeeping/homemaking services than Medicaid allowed, so waivers were granted and these elderly were given Medicaid funds to purchase the additional services privately. Thus for some six or seven years, thousands of two-party checks (in the names of both client and home attendant) were issued by New York City so that additional needed services could be obtained. The problems associated with this system were numerous and predictable: checks were issued to incorrect names; there was no supervision of services; extortion was practiced by both clients and home attendants. In 1980, after several years of false starts, New York City decided to vendorize its program: contracts were drawn up with some 37 various agencies (social services and health, both local and city wide) to provide housekeeping/homemaking services to an estimated 15,000 clients.

Today, there are 60 agencies providing these services to some 35,000 clients through EISEP. In 1987 this represented about 93 million hours of service at a cost of $700 million. JASA holds two of these contracts; its program provides weekly services to about 1,600 clients — some 3.5 million hours of service per year, with an annual budget of $12 million. The home attendant program is growing in size about 8% annually and counting.

New York State’s contribution to the cost of this program has decreased from 25% to 10%, thereby shifting a greater share of the burden to New York City, which is itself under great pressure to reduce Medicaid costs. Approximately 90% of all Medicaid dollars spent on long term care are consumed in New York City, as are about 70% of all federal funds supporting home care. The need to contain these costs has led to inevitable conflicts: when funds are limited and service needs keep growing with the increased elderly population, what trade-offs can be made? Certainly, there are no easy answers.

In the meantime, JASA’s home attendant program operates under strict fiscal controls: every expenditure from salaries to pencils is regulated by New York City’s Medicaid office. In an effort to elevate home attendant services from the perceived position of “home care’s stepchildren,” the 60 EISEP agencies have organized into a Home Care Council; dues paid by member agencies support an office and a salaried executive director. The Council has thus become an agent of its members and can negotiate with New York City and New York State about fiscal constraints.

Although EISEP provides vital services to thousands of elderly people, its continued existence depends on more than the determination and political power of the 60 home attendant service agencies and their Council. The voters must tak...