This chapter argues for the need to build coherent services within the communities where older people live, to have a different policy discussion from the one we have been having for the last 25 years. It begins with a brief description of the prevailing paradigm that governs community-based services for older people and the role of social work within it, quickly cataloging some of the major deficiencies with the current approach. It then suggests a new paradigm that reflects today's understanding of aging and moves quickly to illustrating how this new paradigm is applied in practice in the 27 naturally occurring retirement community (NORC) Supportive Service Programs (NORC-SSPs) in New York City. The chapter concludes by identifying some lessons and implications from this experience, and its replicability to other kinds of communities.
PurposeProviding care for older individuals with chronic illnesses in the community requires a model of service delivery that takes into account both physical health and social health needs. However, packaging care in this way does not fit into existing service or reimbursement structures in the US, and there are few financial incentives that encourage service coordination. Lack of coordinated care can negatively affect access to high quality, appropriate care, putting seniors' physical and mental health and quality of life at risk, as well as their ability to stay in the community. Supportive Social Programs (SSPs), operating in Naturally Occurring Retirement Communities (NORCs), attempt to increase access to care and enhance care quality for aging residents through outreach and service facilitation. Since their inception in 1986, NORC-SSPs have partnered with local health care providers to address both individual and community-wide health issues; however, each sector continues to operate along functional lines, and on a reactive basis. This article presents findings from an evaluation conducted from 2002 to 2006 looking at the feasibility, quality and outcomes of linking health and social services through innovative NORC-SSP and health organization partnerships.MethodsFour NORC-SSPs participated in the study by finding a health care provider to collaborate on addressing health conditions that could benefit from a biopsychosocial approach. Each site focused on a specific population, a specific condition or problem, and created different linkages to address the target problem. Using a case study approach, incorporating both qualitative and quantitative methods, this evaluation sought to answer the following two primary questions: 1) have the participating sites created viable linkages between the participating organizations that did not exist prior to the study; and, 2) to what extent have the linkages resulted in improvements in clinical and other health and social outcomes?ResultsFindings suggest that immediate outcomes were widely achieved across sites: knowledge of other sector providers' capabilities and services increased; communication across providers increased; identification of target population increased; and, awareness of risks, symptoms and healthy behaviors among clients/patients increased. Furthermore, intermediate outcomes were also widely achieved: shared care planning increased across providers; continuity of care was enhanced; disease management improved; and self care among clients improved. Finally, several linkage partnerships were also able to demonstrate improvements in distal outcomes: falls risk decreased; clinical indicators for diabetes management improved; and inappropriate hospitalizations decreased.DiscussionUsing simple, familiar and relatively low-tech approaches to sharing critical patient information among collaborating organizations, inter-sector linkages were successfully established at all four sites. Seven critical success factors emerged that increase the likelihood that lin...
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