GHA 548 Week 5 Community-Based Resources for Aging Populations Example

Federal Money, State Programs and a Church Van: Mapping the Community Resources Older Adults Rely On and Building a Health System's Referral Bridge to Them

[Student Name]

University of Phoenix

GHA/548: Foundations of Gerontology for Health Administrators

Week 5 Assignment

[Instructor Name]

[Date]

The health system, county, programs and figures are composites written for a model paper; laws, program rules and research findings come from the sources listed.

When the senior services director reviewed discharge practice across the system's four hospitals, it turned out that case managers were handing older patients a printed list of community resources last updated four years earlier. Three phone numbers on it were disconnected. Staff rarely knew whether patients had called anyone. This paper maps the community resources available to older adults in the system's county by level of government, evaluates evidence for two programs and describes the referral pathway the system built.

Why Community Resources Matter to a Health System

Most of what keeps an older adult well happens outside clinical settings: meals, transportation, safe housing, social contact, help at home and support for caregivers. When these fail, the result often appears in the emergency department. A health system that discharges patients without connecting them to community resources is sending them home to the same conditions that brought them in.

Federal Programs

The Older Americans Act of 1965 funds a national aging network of state units and local area agencies, which contract for services such as meals, transportation, in-home help, caregiver support, legal assistance and health promotion for people 60 and older. Medicare funds State Health Insurance Assistance Programs, which offer free counseling on Medicare choices. Federal housing programs support subsidized apartments for low-income older adults, and federal nutrition and energy assistance programs help with food and utility costs.

State Programs

States administer Medicaid, including home and community-based services for people who qualify for nursing home care but prefer to stay home. The county's state also funds a prescription assistance program for low-income older adults, a state-funded respite program and adult protective services, which investigates abuse, neglect and exploitation. States also license assisted living and adult day centers.

Local Resources

The county's Area Agency on Aging is the front door to most services. It operates an information line, contracts with 11 senior centers and three meal providers and runs caregiver support. The county transit agency provides paratransit for people with disabilities. Local resources also include faith communities, such as a Methodist church whose volunteers drive older members to medical appointments in the church van, libraries offering technology help and a community college with fitness classes for older adults.

Evidence-Based Community Programs

Some community programs have been tested in trials. The chronic disease self-management workshop, a six-week program led by trained lay leaders, was tested with 952 adults with heart disease, lung disease, stroke or arthritis. Compared with a waiting-list control group, participants improved in exercise, communication with physicians, self-reported health, fatigue and disability at six months and had fewer hospitalizations and hospital days (Lorig et al., 1999). A group program to reduce fear of falling, tested with 434 adults in senior housing, increased intended activity and mobility control immediately afterward, and a year later participants still showed better social function and mobility range; still, the authors judged the benefits modest and saw them shrink over time when no refresher sessions followed (Tennstedt et al., 1998). A program that works in a trial still needs a way to keep working after the last session.

Barriers to Access

Resources exist, but older adults often cannot reach them. Many do not know the services exist or assume they are only for the poor. Some services have waiting lists; the county agency had 160 people waiting for in-home help. Transportation limits participation, especially in rural parts of the county. Forms and phone trees are hard to get through for people with hearing or vision loss, limited English or cognitive impairment. Stigma keeps some from accepting help.

Building the Referral Bridge

The system built a pathway with four parts. First, a current resource directory maintained jointly with the Area Agency on Aging and updated quarterly. Second, a standard screening at discharge and in primary care for older adults, asking about food, transportation, loneliness, caregiving and help at home. Third, closed-loop referrals: case managers send referrals electronically to the agency, which reports back whether the person was contacted and served. Fourth, a community health worker, jointly funded, who helps patients with complex needs complete applications.

Patient One: A Man Living Alone After a Heart Failure Stay

A 79-year-old man discharged after heart failure screened positive for food insecurity and lack of transportation. The agency started home-delivered meals within a week and enrolled him in a self-management workshop at a senior center, with rides from the church van program. He was not readmitted within 90 days.

Patient Two: A Woman Afraid to Leave Home

A 72-year-old woman seen in primary care after a fall said she had stopped going out. She joined a fear-of-falling group at her apartment building, and the agency's health promotion coordinator added monthly booster sessions after the program ended, following the evidence that effects fade without them.

Housing as a Community Resource

Housing is often left off resource lists, yet it shapes every other need. The county has four federally subsidized apartment buildings for low-income older adults, all with waiting lists of more than a year, and a growing number of older renters facing rent increases. Home repair matters as well: a county program funded partly with federal block grant money installs ramps, grab bars and railings for low-income homeowners. The system added the housing authority and the home repair program to its directory and asks about housing stability in its screening, because a fall prevention plan means little to a patient facing eviction.

Paying for the Bridge

The referral pathway costs money: the community health worker's salary, staff time for screening and the agency's time to report back. The system and the agency split the worker's cost, and the system counted the expense against expected savings from fewer readmissions and emergency visits among patients in its value-based contracts. The agency, whose funding is limited and mostly restricted to direct services, received a contract payment for referral management, a model more health systems are adopting as they take on financial risk for older populations.

Partnership Agreements

The system signed an agreement with the Area Agency on Aging covering shared data, referral response times and joint funding of the community health worker and gave the agency a seat on its senior services council. It also agreed to host self-management workshops in two hospital conference rooms.

Measures

The system tracks the share of older patients screened, referrals completed and served, time from referral to service, 30-day readmissions for referred patients and participants' self-reported confidence managing their health.

Conclusion

Community resources for older adults come from federal, state and local sources, delivered through a network of agencies, nonprofits and volunteers. Some, such as self-management workshops, have evidence of reducing hospital use; others have modest or fading effects. The system's printed list is gone, replaced by screening, closed-loop referrals, a shared worker and a formal partnership that connect patients to the resources that keep them well.

References

Lorig, K. R., Sobel, D. S., Stewart, A. L., Brown, B. W., Jr., Bandura, A., Ritter, P., Gonzalez, V. M., Laurent, D. D., & Holman, H. R. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5-14. https://doi.org/10.1097/00005650-199901000-00003

Older Americans Act of 1965, 42 U.S.C. § 3001 et seq. (2020).

Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. The Journals of Gerontology: Series B, 53B(6), P384-P392. https://doi.org/10.1093/geronb/53B.6.P384