According to the AARP, 85% of seniors want to live out their lives at home. However, few options exist for community-based care, especially for those with low incomes and those in rural areas.
Our Vision for Frail Elders in Western and Central New York
Frailty is deferred and elders function successfully within the community with effective health care and supports.
Page Contents:
Background
Challenges
Current Projects
Results
Sources
Background
The Community Health Foundation of Western and Central New York has long been focused on improving the quality of care for frail elders in our communities. Recently, we have begun to see that, as important as that work is, we need to make a greater investment in deferring the consequences of frailty, not just improve care for frail elders. To do this, we need to both increase the opportunities and supports for people to remain more independent and we must reduce the triggers of frailty such as falls, poor transitions of care and ineffective management of multiple medications.
CODA (Creating Options for Dignified Aging), which grew from one specific initiative in two counties to encompass all of our work in this area, applies four strategies to defer frailty: building an elder competent workforce, slowing the consequences of frailty, strengthening community supports and aligning policy and research with community priorities.
Challenges
Some of the challenges we are facing in our work to improve health and health care for Frail Elders Western and Central New York include:
· Quality Care: The United States’ health and long-term care system fail to meet the needs of most patients during care transitions. The frail elderly are one group that is particularly vulnerable when care between settings is not provided in a coordinated, seamless manner.1
· Chronic Disease Management: Large proportions of older Americans report a variety of chronic health conditions such as hypertension and arthritis. More coordinated, preventive approaches to health care could support the effective management of chronic conditions.2
· Frailty Due to Injury: We know that one out of every three people over the age of 65 will fall each year resulting in loss of independence, and falling is one of the top reasons for a move to institutional care. Further, many of these falls will occur at or near individuals' homes and are preventable.3
· Workforce Shortages: The number of trained, professional caregivers is decreasing. There are shortages of home care aides and nurses, along with an out-migration in our regions of younger adults available to enter those careers.4
· Opportunities to Age in Place: According to the AARP, 85% of seniors want to live out their lives at home. However, few options exist for community-based care, especially for those with low incomes and those in rural areas.
Current Projects
Ensuring Livable and Safe Housing and Communities for Elders. The Neighborhood Action Initiative, will be funding up to 10 neighborhood groups in three counties to strengthen the neighborhood’s role in helping seniors remain in their own communities.
The Falls Prevention Initiative engages community-based organizations and health care providers in implementing successful strategies for falls prevention, which can then be used to facilitate practice and behavioral changes throughout our two regions.
Improving Quality Through Better Coordination. As part of the initiative Improving Transitions of Care through Family Caregiver Partnerships, funded organizations are working to develop more effective partnerships between health care providers and caregivers to improve continuity, reduce error and delay, and increase patient control of health decisions among frail elders.
Improving Care through Patient and Family Engagement. The Sharing Your Wishes initiative partners with coalitions in 11 counties to increase awareness of the importance of planning in advance for future health care needs. This is particularly important when an older adult experiences an illness or condition that prevents making or communicating decisions.
Workforce Development. The Geriatric Workforce Initiative includes a series of projects aimed to increase recruitment, retention, and competence among physicians, nurse practitioners, physician’s assistants, home health aides, social workers and other health care related professionals who serve frail elders and their families in Western and Central New York.
Results. Some examples of the results we are beginning to see with these projects include:
· Creation of useful and experience-based tools: The teams in the Falls Prevention initiative have produced a robust how-to manual that includes assessment tools, guidelines for training and exercise programs and home safety checklists. Each of the Quality Improvement Collaboratives on Transitions of Care produced specific tools and templates that are easily transferrable to other settings.
· Promoting Collaboration Among Health Care Professionals: Learning Collaboratives which promote learning, idea exchange and skill development among participants, are an ongoing part of the Neighborhood Action Initiative, Sharing Your Wishes, Falls Prevention, Transitions of Care, and other larger scale CHF programs.
· Increasing Knowledge and skills: All the projects we fund provide health care professionals, communities and families with authoritative and appropriate health care information through presentations, trainings, events, web sites and professional development opportunities.
Other current projects:
Beyond a Warm Body: Enhancing geriatric care in Central New York by improving recruitment and retention of frontline health care workers
Enhancing the Crouse Experience for Patients with Hearing/Vision Loss: Improved operations and staff knowledge
Genesee Community College Geriatric Clinical Rotation for Nursing Students: Creating a more elder-friendly health care workforce by giving nursing students hands-on experience
Geriatric Clinical Practice Series: Educating future nurse practitioners and physician assistants to improve the quality of geriatric medical care
HHA Peer Mentors & Geriatric Care Giver Level II: Improving eldercare in Central New York by strengthening the home- and community-based care workforce
Physician Geriatric Medicine Education
Powerful Tools for Caregivers
Project Home Evaluation: Enabling frail elders to live at home or in a community setting whenever their long-term needs can be safely met
The Tompkins County Long Term Care Workforce Initiative: Identifying resources to improve quality of care through community collaboration
UB Social Work Partnership Program
Sources:
1 National Transitions of Care Coalition: http://www.ntocc.org/Home/PolicyMakers/WWS_PM_Tools.aspx
2 Federal Interagency Forum on Aging-Related Statistics: http://www.agingstats.gov/, http://www.aoa.gov/
3 CDC Falls Data: http://www.cdc.gov/HomeandRecreationalSafety/falls/adultfalls.html
4 WNY Alliance for Person-Centered Care: http://www.wnyapcc.com/aging.html
Photo credit: Photo of elderly woman with glasses courtesy of Tony Lojacono Photography.
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