Both the House-passed version of ACA repeal legislation, the American Health Care Act (AHCA), and the Senate’s version currently under deliberation – the Better Care Reconciliation Act (BCRA) – include a particularly debilitating change: a per capita cap system of funding for Medicaid. This change would dramatically cut federal Medicaid funding to states. It would force states to make difficult decisions between benefit cuts, provider payment cuts and changes to eligibility requirements – or all of these in varying measure – in order to balance their budgets.

Service coordinators in Georgia’s federally subsidized housing properties didn’t have to think very hard when LeadingAge Georgia asked them to name the biggest challenge they faced in serving older residents. 

One responsibility landed consistently at the top of the list.

Service coordinators wanted help addressing the needs of residents who have mental health care needs.

“It was very clear that it was a real challenge for them,” LeadingAge Georgia President and Chief Executive Officer Walter Coffey recently told members of LeadingAge’s Housing Plus Services Learning Collaborative. The collaborative is supporting 12 community-based teams as they develop strategies to coordinate and deliver health and supportive services to residents of subsidized housing properties.

It took 2 years for Coffey to figure out how he could help service coordinators in Georgia help their residents. The answer came when Coffey attended a 2008 conference that the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) co-sponsored in Atlanta.

That’s where Coffey learned about PEARLS—the Program to Encourage Active, Rewarding Lives for Seniors.

PEARLS: Problem-Solving to Overcome Depression

PEARLS is designed to help older adults learn behavioral and problem-solving techniques that have been shown to reduce symptoms of depression and improve quality of life.

Individuals who have been trained as PEARLS counselors implement the program in community-based settings. These counselors work one-on-one with a program participant during 8 in-home sessions. A series of follow-up phone calls reinforces program themes and tracks resident wellbeing.

Problem-solving is at the heart of the program, says Dr. Mark Snowden, PEARLS project adviser.

“When you have overwhelming and unsolved problems, you have an increased rate of depression,” says Snowden. “If you can figure out ways to solve problems, the severity of symptoms of depression will, in fact, decrease.”

Participants also work with a PEARLS counselor to develop a plan to engage in activities that interest them and give them pleasure.

“I knew that this was the answer we had been looking for,” says Coffey about PEARLS. “The problem-solving treatment plan is such a brilliant model. It is almost a coaching model where the elder is coming up with the answers of what they can do and what they want to do. There is great potential for it to support our elders, especially in housing properties.”

A psychiatrist-led team trains PEARLS counselors and reviews each PEARLS case regularly. The supervising psychiatrist can also address other causes of depression and, when necessary, will work with the client’s primary care provider to begin more formal treatment for depression.

The Research behind PEARLS

The University of Washington School of Medicine initially tested PEARLS using a randomized controlled trial in community settings, according to Snowden, who is associate professor in the school’s Department of Psychiatry and Behavioral Sciences.

The study evaluated the impact of PEARLS on levels of depression, quality of life and health care utilization of 138 clients aged 60 years or older. Just over half (51.4%) of the study participants had minor depression and the remainder had chronic depression (48.6%). 

Half of all participants were randomly assigned to participate in PEARLS, and half were randomly assigned to continue with their usual medical care.

Over 12 months, individuals who participated in PEARLS were more likely than those who did not receive PEARLS to:

  • Have a 50% or greater reduction in depression symptoms.
  • Achieve complete remission from depression.
  • Have greater health-related quality-of-life improvements in both functional and emotional well-being.
  • Have lower rates of hospitalization.

Service Coordinators and PEARLS

After Coffey discovered PEARLS at the CDC/SAMHSA conference, LeadingAge Georgia partnered with the Fuqua Center for Late-Life Depression at Emory University to train service coordinators in the PEARLS model.

Service coordinators were initially hesitant to join PEARLS, which they perceived as “very clinical,” says Coffey. But those who decided to participate in the training were glad they did, he says.

“They saw it as a way to really help their residents, to bring them out and engage them in the life of their community,” he says. “Later, (the service coordinators) told us, ‘This is the greatest addition to my job in years’ and ‘This is a skill that is really going to change (residents’) lives.’”

In addition, says Coffey, service coordinators found that their PEARLS training and experience helped them engage more successfully with local health care providers, including residents’ general practitioners.

“They were using the right language,” says Coffey. “They were able to say, ‘I assessed a person this way, and this is what we are learning.’ So they got more respect from health care providers. They got more feedback. They were also a lot better equipped to connect resident with the services they needed.”


The LeadingAge Workforce Cabinet has spent a year defining the skills sets for personal care attendants, care coordinators and middle managers to deliver effective supports and services. 

Now, the Cabinet wants to make sure that nursing homes, home health agencies and housing properties will use those competencies to strengthen their workforces.

The Workforce Cabinet -- a group of educators, state association executives and LeadingAge provider members -- discussed in March strategies and resources that could help LeadingAge provider members create healthy workplaces and improve the workforce.

Creating Healthy Workplaces

During their March meeting, members of the Workforce Cabinet worried that the current economic downturn could make LeadingAge members too complacent about the need to address persistent workforce challenges facing the aging field. The current economic climate has helped to stabilize turnover rates. 

But those rates are likely to rise sharply again as soon as the economy recovers.

An Organizational Readiness Assessment could help a LeadingAge member objectively examine its workplace, identify that workplace’s strengths, and assess how it might be improved. Staff members at all levels could use the tool to record their perceptions of the benefits and challenges of working for the organization. 

Those responses could then be used to assign a score to the organization’s work environment and culture.

The Cabinet discussed a package of supplementary materials that could be targeted to an organization’s specific score on an Organizational Readiness Assessment. Those resources could help the organization address and resolve any workplace issues that surfaced during the assessment.

“It’s difficult to attract and retain qualified workers unless your organization supports those workers after they arrive,” says Natasha Bryant, managing director and senior research associate at the Center for Applied Research. “A readiness assessment is really the first step in this process. An organization that carries out this type of assessment will be in a much better position to make full use of the competencies that the Workforce Cabinet will release next fall.”

Improving Staff Training

The Workforce Cabinet plans to help nursing homes, home health agencies and housing providers incorporate its workforce competencies into their hiring and training practices. The Cabinet believes that these providers might benefit from:

  • A checklist that would outline specific knowledge and skills that workers would need to meet each competency. 
  • A package of resources that would guide the organization in helping workers achieve the competencies they lack.

“The Cabinet’s primary goal is to make the competencies easy to use so that providers will use them,” says Bryant. “We would like to offer providers an all-in-one package that takes them from the readiness assessment right through to actually using the competencies to hire, orient, evaluate and train personal care attendants, care coordinators and middle managers.”

About the Workforce Cabinet

The Workforce Cabinet held its first meeting in April 2012 and will serve until April 2014. 

The cabinet is co-chaired by Barry Berman, chief executive officer (CEO) of Chelsea Jewish Home Foundation in Chelsea, MA, and Frances Roebuck Kuhns, president and CEO of WRC Senior Services in Brookville, PA.



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