A Roadmap to Coordinated Care For Community-Based Services

For Older Adults

John Zabawa, President/CEO, and Jane Yeager, Sr. V.P., Coordinated Care

2007 Joint Conference, American Society on Aging

and The National Council on Aging

Seniors’ Resource Center began in 1978; the Jefferson County Council on Aging, representing Colorado’s largest population of seniors, saw a need to integrate programs/services for older persons.

History and Mission

SRC’s Mission• Senior’s Resource Center works

in partnership with older persons and the community to provide centralized and coordinated service, information, education and leadership helping to assist seniors in maximizing their independence and personal dignity.

Location 2004 -- 60+

2020 -- 60+

Absolute Change

Denver Metro

270,000 575,000 305,000

Colorado 620,000 1.16 million

540,000

U.S. 44 million 74 million 30 million

What Were the Steps in Creating

A User-FriendlyCare Coordination

Approach to NavigatingVaried Care Options for

Older Adults andTheir Caregivers?

2005: An Organizational Assessment

• 50 interviews with senior managers, board members, staff and volunteers

• SWOT analysis• Ensure alignment between mission,

vision and business plan• Create 10-20 year vision of a

thriving organization• Review quality improvement plans,

new funding sources, additional partnerships and expansion efforts

•We are a “good” organization with the

opportunity to be “great.”

-- Jim Collins’ concept of “Good to Great”

The Hedgehog Concept

Best at: Service quality

Relations with other agencies

Financially solvent

Diversified board

Reputation

Flexibility

Economic Engine Funding

Grants

Fees

Donations

Volunteers

Passionate About Community/ Mission/Needs

Board, Staff Respect

Big Hairy Ambitious Goal

A New Strategic Plan is Born5 areas of concentration:

• Modernizing Care Coordination• Increasing and diversifying sources of resource

development• Maximizing growth areas geographically, new

partnerships, and new lines of service• Increasing organizational capacity• Taking a purposeful leadership role on public

issues that affect seniors

...And A Realistic View of Seniors’ And Caregivers’

Challenges in the Community

• Increasingly fragmented support options

•There is no such thing as “one-stop shopping” for help in health care, from government, from non-profits and the private sector

In Other Words, How do Seniors Navigate a Maze of

Programs and Services?

The Result:A Plan for A Person-

Centered Continuum of Service Delivery

•Cultural change: Silos to coordination

• Identify key external linkages & partnerships

• Talk with geriatric practices & hospitals

• Work with mental health providers• Reach out to internists• Seek foundation grants to increase

capacity

New Relationships to Create a “What Else Do You Need” Approach to

Customer/Client Service

And Aha! •Seniors’ Resource

Center made new friends in the philanthropic sector -- among medical providers; with businesses that volunteered time, labor and skill; and with other community agencies.

Examples ofHOW the NEW CoordinatedCare Modelat Seniors’ ResourceCenter WILLHELP OLDERADULTS In Colo…

A “Community Care Navigator” At A Doctors’ Office for 17,000 Patients

• Grant-funded position to identify isolated or at-risk seniors who need community-based services.

• Reduce strain on medical services from seniors not having access to, or being aware of, community-based services that can prevent and mitigate health problems.

Training Community Members To Recognize Depression in Seniors

• Through a federal grant, SRC launched “Senior Reach” with two major centers for mental health.

• 600 community members are now trained to look for signs of mental and emotional health conditions that can go unrecognized and untreated in older adults.

Preventing Injurious Falls in Fragile and Unwell Senior Citizens

• A hospital refers at-risk seniors for home repairs, like adding grab bars and wheelchair ramps to homes of fragile seniors.

• Lowe’s volunteers offer labor & supplies. Safeway pharmacies review prescriptions for drug-interaction side effects - dizziness.

A Database to Coordinate Services to Clients Across SRC Programs

• The CO Health Foundation made a grant for SRC to create a database to track consumer care needs, schedules, functional limitations, inter-program referrals and service preferences.

Recognition by a big foundation: IT is key to effective senior service delivery.

WHAT DOES IT ALL MEANFOR OUR CLIENTS?

Ask Dottie.

Dottie is 80 years old. She turned to Seniors’

Resource Center for assistance in living more independently

at home.

With 1 call, Dottie obtained:

• Funds to fix her roof• Help with a furnace inspection• Low-Income Energy Assistance• A grant for hearing aids• A personal care provider to

help with homemaking• & found locations where she

could go eat meals with other seniors.

Dottie Loves Life!

For more information, contact…

Jane Yeager, Senior Vice President, Care Coordination, (303) 235-6977