Community-Based Supports and Services for Older Adults: A Primer for Clinicians

Siegler, Eugenia L.; Lama, Sonam D.; Knight, Michael G.; Laureano, Evelyn; Reid, M. Carrington

doi:10.1155/2015/678625

Cited by 78 publications

(57 citation statements)

References 17 publications

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“…An estimated 70% of older adults in the U.S. will need HCBS at some point [ 24 ]. While many older adults want to learn about HCBS, they often lack knowledge of the available services in their area, how to secure them, or how to pay for them [ 24 , 25 ]. Similarly, medical providers may not know or understand how to refer and coordinate HCBS services [ 25 , 26 ].…”

Section: Introductionmentioning

confidence: 99%

Home and community-based services coordination for homebound older adults in home-based primary care

et al. 2018

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BackgroundMedically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients.MethodsAn online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members.ResultsNearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated ‘most’ or ‘all’ of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was ‘difficult.’ The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was ‘difficult’ or ‘very difficult’ to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05).ConclusionsDespite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

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Section: Introductionmentioning

confidence: 99%

Home and community-based services coordination for homebound older adults in home-based primary care

et al. 2018

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“…Elder service agencies constitute a broad array of programs and services designed to help older adults remain safely in their homes and delay or prevent institutionalization (22). Agencies include senior centers that offer meals, exercise programs, as well as educational and wellness programs, and case management programs that connect older adults with in-home supports such as home-delivered meals and other services, including transportation, legal assistant and benefits.…”

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confidence: 99%

Expanding palliative care’s reach in the community via the elder service agency network

Reid¹,

Ghesquiere²,

Kenien

et al. 2017

Ann. Palliat. Med.

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Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the US, highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care “champions” in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.

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“…Knight, E. Laureano, M.C. Reid [4], when providing social services at home, conditions, which are created for the recipients to remain at their home, in their communities as long as possible, enable them to avoid institutionalisation and to reduce their social exclusion.…”

Section: Research Results Analysismentioning

confidence: 99%

“…Social services in the community and at the person's home are appreciated due to the increasing social security and social cohesion and reduced impact of stigmatisation [2]. It is recognised that social services in the community and at the person's home enable the person to live with dignity and maximal autonomy at their home rather than be separated from their community [3,4].…”

Section: Introductionmentioning

confidence: 99%

The specifics in the work of social workers when rendering social services at the person's home

Raudeliūnaitė

2019

SHS Web Conf.

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The objective of the study is to highlight the specifics of the work of a social worker when rendering social services at the person's home on the basis of the experience of social workers. Qualitative research strategy was used, including semi-structured interview. The study revealed a wide spectrum of the activities of the social worker when organising the provision of social services at home: the identification and assessment of the need for a service, the planning, provision, coordination and assessment of the assistance or care at the person's home, the involvement of the service recipient in decision-making, the involvement of close relatives of the service recipient, teamwork, cooperation with other institutions, and improvement of skills of the employees. The study revealed the benefit of social services at the person's home to the recipients of the services: living at their homes, they do not feel so lonely, they feel safe, needful, capable of benefiting from the needed assistance. Difficulties, which arise when cooperating with the recipients of social services at home, are the following: people provide false information when identifying the need for a service, mental disorders of the service recipient, dissatisfaction with the rotation of the visiting care workers, complaints regarding the lack of communication. Organisational limitations of bodies providing services are linked to formalism, shortage of the staff, time restrictions for services, lack of transport, unavailability of services due to the limited financial resources of service recipients.

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Community-Based Supports and Services for Older Adults: A Primer for Clinicians

Cited by 78 publications

References 17 publications

Home and community-based services coordination for homebound older adults in home-based primary care

Home and community-based services coordination for homebound older adults in home-based primary care

Expanding palliative care’s reach in the community via the elder service agency network

The specifics in the work of social workers when rendering social services at the person's home

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