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LeadingAge magazine January/February 2012

Building Ties to Community Organizations

by Debra Wood, R.N.
In life and in business, forging relationships and relying on others beats going it alone, according to providers who have created lasting ties with other organizations in their communities.

“It takes a community to care for older adults,” says Dianne Kujubu Belli, chief administrative officer at Keiro Senior HealthCare in Los Angeles. “Keiro and the Japanese-American community are one and the same.”

 

Partnering To Improve Seniors’ Health

LeadingAge Jan-Feb12 Community orgs healthy genki 335 wide
Keiro Senior HealthCare

Keiro promotes genki living (genki means “healthy, energetic” in Japanese), no matter where clients call home.

Keiro operates three campuses and cares for more than 600 people in its independent, assisted living, intermediate care and nursing home communities. Four of its eight founders recently attended the organization’s 50th anniversary luncheon, and one continues to serve on the board of directors.

As part of the celebration, the Institute for Healthy Aging at Keiro, an education and resource center formed in 2006 to help people achieve the quality of life they desire, presented a Genki Living Expo, focusing on the eight dimensions of wellness. Genki means healthy and energetic in Japanese. More than 3,000 people from the community came.

“We brought together resources for healthy living, and it was our gift to the community,” Belli says.

The institute provides conferences, consultations and other programs to residents and older adults who do not reside in nursing homes. It has partnered with the UCLA Longevity Center, the Partners in Care Foundation and the Alzheimer’s Association Southland California Chapter to bring evidence-based programs to the community.

 
LeadingAge Jan-Feb12 Community orgs volunteer and client 335 wide
Keiro Senior HealthCare

Volunteerism helps enhance the quality of senior life at Keiro Senior HealthCare.

About 30 specially trained Keiro volunteer coaches teach the UCLA Memory Enhancement Course, the University of Minnesota’s Savvy Caregiver’s program and Kaiser Permanente’s A Matter of Balance program, all based on scientific evidence, to members of Keiro’s Nikkei Senior Network, a group of 40 community-based organizations, including churches, senior centers, temples and other entities that serve Japanese-American older adults in Southern California. The programs are so popular; Keiro schedules them a year in advance.

“It’s a robust volunteer program,” says Belli, adding that it meshes with the organization’s philosophy that people who volunteer are healthier. All together, more than 800 people from the community volunteer at Keiro.

More than 200 community groups have supported Keiro. Girls from the Japanese American Optimists’ basketball teams raise money for resident activities, Boy Scouts help with events, gardening groups trim bonsai trees on the grounds, and groups from faith communities entertain the residents.

“None of this happens without the community,” Belli says.

 

Reaching Out in Multiple Directions

Jacqueline Carson, chief executive officer of Sanborn Place, Home Care & Day Services, considers her organization a community resource and an extension of the Reading, MA, community it has served for nearly 30 years. She gives of herself and her organization and, in return, reaps the bounty of a supportive society.

“My philosophy is what goes around, comes around,” Carson says. “What you give, you get. We’re in business to serve. People respect that, and it’s part of our success.”

Sanborn Place collaborates with many organizations and other providers to ensure its residents receive the services they need.

For example, Carson serves on the board and raises funds for the Y. In turn, the Y offers Sanborn Place residents a discounted rate, and Y staff members provide an exercise reconditioning program three times weekly at Sanborn Place.

Sanborn Place also is working with the town’s Reading Senior Center on a reorganization plan. Senior center clients sometimes go to Sanborn Place for activities, and Sanborn Place residents attend the senior center for meals and activities. The center and Sanborn Place share vans and juggle schedules if one of their vans is in for service.
 
Even though Sanborn Place owns a home care agency with registered nurses, it contracts with the Middlesex Visiting Nurse Association for skilled nursing, rehabilitative and hospice services. Sanborn Place manages residents’ care, working with hospital discharge planners, the VNA and physicians. The VNA uses Sanborn Place’s home health aides to provide bathing and aide care to residents and will develop a long-term plan to help a resident remain independent.

“We work as a team, because it serves the residents and families in the best interest,” Carson says. “We problem-solve together.”

Sanborn Place will try to find a solution to meet the needs of every resident. That may mean additional home care. Staff members are trained in the care of feeding tubes and oxygen. Only about five percent of its residents annually transfer to a nursing home.

“We pretty much can do everything a nursing home does,” Carson says. “We are a housing and services program at its max. We do a lot of maintenance care things.”

Carson says that residents feel reassured that Sanborn Place will work to help them age in place and adjust plans as additional disabilities crop up. She finds healthy residents coexist well with those who have more difficulties with life.

“We’ve done a wonderful job of inclusion,” Carson says. “People look at it as a security that when and if something happened to them, they will not be placed somewhere else. They have a high tolerance and understanding of each other’s disabilities.”

Sanborn Place readily pitches in at times of community need, offering to shelter residents from another community during a power outage and providing space for the local Rotary Club to meet. A few years ago, the club donated a 14-seat passenger van for Sanborn Place, and it has set up a foundation for the community.

Carson also believes in supporting local merchants. Sanborn Place purchases everything possible locally.

“We buy meat from the meat man and fish from the fish man,” Carson says. “We are entrenched in the community.”

 

Establishing Community Connections

Recognizing a need for better transitions between care settings, Pat Sprigg, president and CEO of Carol Woods Retirement Community in Chapel Hill, NC, sought and received a three-year planning grant of nearly $1 million from The Duke Endowment in Charlotte, NC, to pioneer Community Connections, a community-based collaboration to increase support for older adults transitioning from hospital to home.

“We thought if we could align on a common agenda and get all of the stakeholders together, we could prevent unnecessary hospitalizations,” Sprigg says.

About four years ago, Carol Woods began building strategic partnerships with the North Carolina Department of Health and Human Services, with the UNC Health Care System in Chapel Hill; Piedmont Health Services in Carrboro, NC; Community Care of North Carolina in Raleigh; more than 100 public and private organizations; and consumers in two counties. Carol Woods convened a two-day planning meeting with community-based organizations with help from the UNC Center for Aging Research and Educational Services.

“What emerged was not just priorities but community buy-in,” Sprigg says.

To date, 21 agencies have signed formal agreements with the Chatham-Orange Community Resource Connections for Aging and Disabilities.

“It’s to streamline information and access to long-term care services,” says Sprigg.

Carol Woods brought together agencies working on preventing readmissions, and they came up with a list of pilot projects that could ease the transition, such as a nurse who could call the older person discharged from the emergency department at home to follow up and answer questions. When that initiative proved successful, the hospital assumed responsibility for funding the position for other transition efforts.

Community Connections organizers also recognized that falls led to a downward spiral and then came up with a balance and fall workshop and balancing classes to help keep older adults on their feet. They also have launched a telehealth pilot at a local community health center. None of the projects duplicate existing services; instead, they complement efforts.

“It’s constantly looking at service delivery, workforce and public policy, and making sure they are in lockstep,” Sprigg says.

Some of the organizations compete, such as UNC and Duke, but they have agreed to cooperate, pool resources and share information.

“It’s building awareness, and getting people to check their egos at the door for the greater good,” Sprigg says.

Sprigg finds that Carol Woods’ sterling reputation, and not having a “dog in the fight” has helped it become a change agent. Carol Woods had already implemented successful programs to keep people at home. She finds other organizations want a piece of its coordinated, case-management approach working for them as well.

In the first four years, Sprigg reports success. Organizations regularly call her wanting to join the Community Connections efforts. A follow-up survey found that 89 percent of the service providers say that by participating they have learned something new about available services in the community, and 94 percent report they have increased connections with colleagues from other agencies. And 66 percent have increased their partnerships with health providers to improve transitions.

Community Connections’ success has led to an additional grant of $296,000 from The Duke Endowment to continue the initiative for two years, developing best practices and helping sites throughout the state implement evidence-based transitions interventions.

Sprigg explains that many organizations often complain that with current reimbursements and funding they cannot meet the community’s needs.

“We tell them that there is enough money in the system,” she says. “If you can put in a collaborative, preventive model and stop the turnstile back into the hospital, you can save money. There are enough resources in the system, if everyone is willing to augment and not duplicate.”

 

A Collaborative Effort to Reach Out to Isolated Seniors

In Oakland, CA, a LeadingAge Leadership Academy fellow is part of an effort to create a community outreach program to help vulnerable populations (such as frail elderly) more easily understand and access community resources. The goals include offering more help to older and disabled adults while reducing the number of calls to 911 for non-life-threatening situations.

 
“There are a lot of ‘frequent flyers’ who call 911 after falling and then go to the hospital,” says Donna Murphy, social services coordinator at Sojourner Truth Manor, a HUD 202 affordable housing community in Oakland, CA, part of Christian Church Homes. “Then they are sent home with no resources, no information, and then they fall again.”

Murphy’s original idea for her Action Leadership Project was to reach out to first responders, such as firemen or police officers, and educate them about potential signs of trouble among older citizens. “Maybe when a fireman [answers a call] he sees hoarding and clutter, or an empty refrigerator, and can pass that information on to the right people.  This could reduce the number of hospitalizations and the number of 911 calls.”

Once she began researching her idea, Murphy discovered that the Senior Services Coalition of Alameda County had already begun work on its own “Local Safety Net Initiative,” a program to create a safety net for seniors with the involvement of police and fire departments.  She joined their effort and discovered a lot of allies—from an Oakland City Council member wanting first responders to recognize people about to “fall through the cracks” to other aging-services providers, Meals on Wheels providers and city agencies.

Hayward and San Leandro, two communities adjacent to Oakland, have already launched similar programs, and the coalition Murphy is involved in is trying to replicate the idea in North Oakland, an area home to an estimated 6,500 seniors, more than half of them over age 75.

“We got foundation money to hire a coordinator to put things together and put things into action,” says Murphy. “We’re trying to get all the people who would see an isolated senior, and help them get information and referrals, and know who they can call, who they can go to.”

 
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Debra Wood, R.N., is a writer who lives in Orlando, FL.