North Shore Elder Services Area Agency on Aging Area Plan Life. Made Easier.

Transcription

1 North Shore Elder Services Area Agency on Aging Area Plan Life. Made Easier. 152 Sylvan Street Danvers, MA age-info TTY

2 Table of Contents North Shore Elder Services Planning and Service Map... 2 Narrative... 4 Goals and Objectives FFY Attachments Attachment A: Area Plan on Aging Assurances and Affirmation Attachment B: AAA Information Requirements Attachment C: AAA Organizational Chart Attachment D: Form 1 - AAA Corporate Board of Directors Attachment E: Form 2 - AAA Advisory Council Members Attachment F: Form 3 - AAA Funded Services Attachment G: Form 4 - AAA Focal Points Attachment H: Projected Budget Plan FFY This document was prepared and written by: Cheryl Krisko, RN, Chief Program Officer Rhonda Gauthier, M. Ed., Director of Community Services North Shore Elder Services Area Plan Page 1

3 Planning and Service Area North Shore Elder Services Area Plan Page 2

4 North Shore Elder Services Area Plan Page 3

5 Narrative North Shore Elder Services Area Plan Page 4

6 Introduction: North Shore Elder Services, Inc. (NSES) was founded in 1976 as a private, not-for-profit, 501 (c) (3) organization to plan, coordinate, and provide services and information regarding older adults and their families in five North Shore communities: Danvers, Marblehead, Middleton, Peabody, and Salem. A seventeen member Board of Directors representative of the five communities governs the agency. NSES functions as an Aging Service Access Point (ASAP) organization designated by the Commonwealth of Massachusetts and as an Area Agency on Aging (AAA) under federal auspices. A consumer-directed advisory council provides guidance in program development, makes recommendations regarding the award of federal funding, and participates in program evaluation. NSES was one of the founding members of the Aging and Disability Resource Consortium of the Greater North Shore (ADRCGNS). In addition, NSES manages the statewide Money Management program under contract with the Executive Office of Elder Affairs with the cooperation of AARP and Mass Home Care. Key programs and supports offered by NSES include Care Management, Consumer Assessment and Care Planning, Information and Referral Services, Care Transitions Programs including Options Counseling, Transition Support for consumers returning to the community from nursing facilities, Live Well, Age Well Programs, Housing Options, Nursing Home Ombudsman, Money Management, and the At Your Side Medical Advocacy program. Mission Statement The mission of North Shore Elder Services (NSES) is to serve the functional needs of older adults residing on the North Shore of Massachusetts and to provide support, information, and service to them and their families. Our vision is for each individual to live as independently as possible in locations of their choice for as long as possible. NSES has served our communities primarily through the provision of programs and services funded by the Massachusetts Executive Office of Elder Affairs that promote the integrity, rights, and independence of all seniors and their caregivers. Specifically, we accomplish this through the provision of home care services, nursing assessments, protective services, information services, nutrition program, nursing facility ombudsman program, and an array of community services provided by volunteers (e.g., money management, medical advocacy, companions, and grocery shopping). History North Shore Elder Services was incorporated in 1976 as a Home Care Corporation. Home care services are provided to people age 60 and older living in Salem, Peabody, Danvers, Marblehead, and Middleton. In 1978, the federal government designated NSES an Area Agency North Shore Elder Services Area Plan Page 5

7 on Aging. Funding from the Older American Act is used to support the local Councils on Aging, helping to promote the development of elder services in our five local communities. Most of this funding supports congregate meals, home-delivered meals, transportation, and other senior center activities. As a state-designated Aging Service Access Point (ASAP), North Shore Elder Services is a leader in the care of older adults, promoting their independence and a dignified quality of life. More than 3,500 clients and their families avail themselves of this valuable community resource annually. NSES s programs continue to evolve to meet the ever-increasing and changing needs of an aging population and the 34,260 adults over 60 who live in the service area. NSES continues to expand its vision beyond home care and nutrition. Our newest programs have been developed to meet the emerging needs of transportation, housing and healthcare in the 21st century: At Your Side medical advocates provide support and advocacy for frail elders as they navigate their way through today s complicated health care system, providing assistance and an escort to medical appointments. Live Well, Age Well is an array of proactive, evidence-based programs (e.g., lifestyle management, fall prevention, nutrition counseling, fitness coaching, and virtual support) providing information on health and wellness as well as chronic disease management. North Shore REACT (Regional Elder Assistance Coordinating Team) is a multi-disciplinary team of community based first responders, crisis, public safety and medical teams who serve elders (60+) on the North Shore. The goal of REACT is to work collaboratively to improve the safety and well-being of the elders in our five communities. Over the Rainbow Supper Club provides services and support for our elders in the lesbian, gay, bisexual, and transgender communities who may otherwise have found themselves alone and isolated. Our vision has broadened from supporting elders to also supporting families in need of aging services. NSES continues to create new partnerships by collaborating with the medical and health care sectors and responding to the opportunities and challenges of national and state health care reform initiatives. Since 1976, our goal remains the same: Life. Made Easier. for elders and their families. North Shore Elder Services Area Plan Page 6

8 Summary Details of the Older American Act: The Older Americans Act (OAA) of 1965 sought to ensure that all elders, especially the most isolated and disadvantaged, have an adequate retirement income; the best possible physical and mental health, without regard to economic status; suitable and affordable housing; a choice of community services which provide a continuum of care, an opportunity for employment; retirement in health, honor and dignity; the opportunity to participate in and contribute to meaningful activity; immediate benefit from proven research knowledge which can sustain and improve health and happiness; and protection against abuse, neglect and exploitation. Title III of the OAA, as amended, authorizes funding and provides parameters for the operation of programs which address the entire spectrum of elders needs through in- home and community based initiatives. NSES grants Title IIIB Supportive Service funding to the Councils on Aging for programs that include transportation, respite and out-reach. Through these successful partnerships NSES has created a strong network of community agencies that support the elderly. Though special emphasis is placed on elders with particular economic or social needs, all Americans over age 60 may benefit from OAA and Title III programs. Programs and Services North Shore Elder Services offers a wide variety of services and programs to meet elder care needs. These include: Information and referral services from certified aging specialists in elder care services and aging issues Care management by social service and nursing professionals Home care services (e.g., housekeeping, personal care, etc.) Family caregiver support Options counseling in assessing long-term service options and planning for present and future needs Health benefits/insurance advice Money management assistance (check writing and bill paying) Home-delivered meals for homebound elders Senior dining locations throughout the North Shore North Shore Elder Services Area Plan Page 7

9 Nursing home ombudsmen Elders- in- crisis workers who investigate abuse/neglect Housing options regarding local supportive living and congregate residences Legal Services Mobility management for transportation to medical appointments North Shore Elder Services Area Plan Page 8

10 Older Americans Act Core Programs North Shore Elder Services is a creative, innovative agency providing a wide array of services designed to promote health and independence for elders and disabled adults living in the community. Title III funding enhances many of the core services we provide. Our programs are reviewed and monitored to ensure they are meeting the goals and objectives established to help fill unmet needs. A consumer directed Advisory Council provides guidance in program development, makes recommendations regarding the awarding of federal funding and participates in program evaluation. The Advisory Council is highly dedicated and advocates for and promotes services that nurture elder independence, promote and protect elder rights, and ensures that the programs NSES is running are effective and meeting the needs of the community. Transportation, outreach, information and assistance, and care management are evaluated to assure that the low-income, isolated elders, socially isolated elders, and disabled adults are all afforded the same opportunity to receive services. The Council is scheduled to meet monthly. NSES Planning and Service Area (PSA) includes elders who are living alone (isolated); low income elders; minority elder populations including LGBT and limited English proficient elders. There are no designated rural areas in the PSA and identified Native American populations are nominal. Within the NSES catchment area, need is most apparent in the communities of Salem and Peabody, where more than half of all residents aged 65 and over have a disability. Similarly, these same two cities include multiple census tracts with high concentrations of low-income populations, and where between 40% 60% of those 65 and over are living below the poverty line. Up to 20% of Salem and Peabody residents are foreignborn as compared with less than five percent in the surrounding towns of the catchment area. Up to 10% of the population of these two towns has less than a 9th grade education. In response to the 2013 Municipal Needs Assessment Results, and the resulting top three concerns of transportation, housing and healthcare, North Shore Elder Services will continue to present free health fairs and seminars in our service area to inform the public of our programs as well as community programs that address health care issues and ancillary device services. Offering free hearing clinics and free NeedyMeds prescription cards are ways to address the particular health care need of assistance with prescription and medication costs. The Carroll Center for the Blind has a satellite office at North Shore Elder Services to provide support and devices that make life easier for persons with low vision. Weekly segments on North Shore Radio Retirement Radio present the community with programs and topics that support and enhance the consumer s ability to maintain their health and independence in their homes and community. North Shore Elder Services Area Plan Page 9

11 Table 1 provides a brief overview of the current NSES Older American Act core programs funded by Title III and the populations they serve. Many of these programs reflect multiple Administration on Community Living (ACL) focus areas. Provider/Name of Program Title III Funding Source Brief Description Peabody COA Title IIIB The Peabody COA Outreach provides information and referrals concerning issues related to health insurance, housing, congregate and home delivered meals and advocacy. Danvers COA Title IIIB Transportation services for Danvers seniors and/or disabled via a lift-equipped van with primary focus on medical appointments with secondary service focus on transportation of day care/respite situations. Salem COA Title IIIB Transportation services for two part-time drivers to maintain transportation services currently offered to Salem s senior citizens. Marblehead COA Title IIIB Marblehead Outreach Program assists socially isolated elders, including minority and low income seniors, to access programs, services and entitlements by providing information and referral services and help with the completion of forms. The program uses the media to educate seniors and their caregivers. Middleton COA Title IIIB The Outreach Program provides health presentations and clinics, activities to alleviate social isolation, and housing advice. New England Homes for the Deaf Neighborhood Legal Services Elder Law Project NSES Long-Term Care Ombudsman Title IIIB Title III B Title III B Language-accessible outreach, recreational activities, information and referral as well as social supports that prevent isolation and loneliness, which can be a particular problem for hard of hearing elders are provided. Free civil legal services to elders, focusing services on elders in the greatest social and economic need, in the following issue areas: subsistence income, maintenance, public benefits, health care access and costs, loss of housing, and protective services. Assures that residents of all ages living in long -term care facilities in the planning service area have an independent advocate to help protect their rights. Population Served Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated elders, disabled adults Low income elders, isolated elders, socially isolated, disabled adults Isolated and socially isolated low income elders and adults with disabilities North Shore Elder Services Area Plan Page 10

12 Provider/Name of Program NSES Money Management NSES Information and Referral NSES Congregate Meals NSES Home Delivered Meals NSES Live Well, Age Well Healthy Living Programs NSES Improved Health Outcomes for Life At Your Side NSES Family Caregiver Program Title III Funding Source Title III B Title III B Title III C Title III C Title III D Title III D Title III E Brief Description Assists elders and adults with disabilities with the task of monthly bill paying and other needed assistance that enables them to maintain financial independence. Connects consumers with information and supports to make informed choices about their lives Offers hot, nutritious meals at several community sites located in the planning service area. A new site is geared towards LGBT elders. Delivers nutritious meals to people over 60 who are homebound and unable to prepare meals. Incorporates Evidence Based Disease and Disability Prevention programs to empower adults to self-manage for improved quality of life. Incorporates medication review and management options with a medical advocacy program. Provides support to caregivers through in-home assessments, information and referral, counseling and support groups, education and training, (including evidence based training) and respite care. Population Served Elders, Low income elders and adults with disabilities, isolated, socially isolated, minority individuals Elders and adults with disabilities and their caregivers, isolated elders, low income elders, minority elders, socially isolated elders Elders, low income elders, minority elders, socially isolated elders Elders, low income elders, isolated elders, minority elders, socially isolated elders Elders and adults, elders and adults with disabilities, low income, minority individuals Isolated elders, low income elders, minority elders, socially isolated elders. Caregivers of elders and adults with disabilities, isolated elders, low income elders, minority elders, socially isolated elders North Shore Elder Services programs and services are available to all elders of any ethnic background. Spanish, Portuguese and Russian speaking case managers are on staff. Three case managers and one information and referral specialist are learning American Sign Language. North Shore Elder Services has contracts with agencies to provide interpreters and have access to the language line if needed. North Shore Elder Services Area Plan Page 11

13 Administration on Community Living Discretionary Grants North Shore Elder Services provides and coordinates evidence based programs throughout the five communities we serve. These programs include: My Life, My Health: Chronic Disease Self- Management; Diabetes self-management; A Matter of Balance: Reducing the Fear of Falling; Healthy Eating; Powerful Tools for Caregivers; and the Care Transitions Intervention. NSES offers programs in conjunction with the Healthy Living Center of Excellence at Elder Services of Merrimack Valley and the Aging and Disability Resource Consortium of the Greater North Shore (ADRCGNS). As part of the ADRCGNS, programs are coordinated by use of a regional calendar, allowing more opportunities for consumers to attend a session of their choosing. NSES is a founding member of the ADRCGNS which has been in operation for close to ten years. The ADRCGNS was established to create a no wrong door philosophy of care for consumers: a single, coordinated system of information and access for persons seeking long term services and supports, regardless of age or disability. The leadership of the ADRCGNS is made up of three ASAPs, one Independent Living Center, the Elder Services Plan of the North Shore, and the North Shore Career Center. The ADRCGNS collaboration has established a strong commitment to support consumer choice and direction, promote community activation, and research and pilot innovative models of care with the goal of improving consumer access, engagement, and quality of life outcomes. Navigating Across Care Settings (NACS): Choices for Successful Transitions The Commonwealth of Massachusetts was selected and received a care transitions grant from AoA to implement a care transitions project. Navigating across Care Settings (NACS) was based on the Care Transitions Intervention developed by Eric Coleman, MD. The model was designed to support consumers as they transitioned from the hospital to the home setting and prevent unnecessary re-hospitalizations. NACS proposed to support the care transitions model with PLUS! programs to provide additional support, education, and empowerment. Programs included under PLUS! are: Options Counseling At Your Side Medical Advocacy Chronic Disease Self-Management Workshops Mobility Management A Matter of Balance: Reducing the Fear of Falling Caregiver Supports North Shore Elder Services Area Plan Page 12

14 Safe Passages/Root Cause Analysis The ADRCGNS, led by the Greater Lynn Senior Services research and planning department, undertook a root cause analysis of the greater North Shore area. In addition to its leadership agencies, key partners in this effort were Northeast Health Systems and North Shore Medical Center, as well as multiple rehabilitation and skilled nursing facilities; visiting nurse and home health agencies; physician practices; community health centers; long-term support services providers; and a wide array of organizations delivering other critical supports. This project was titled Safe Passages and attempted to uncover how to create a seamless system for our area that would promote community choice, healthy behaviors, and improved health outcomes. Based on a comprehensive root cause analysis of preventable re-admissions, we know that the population in our ADRCGNS area is more likely than the state to experience hospitalizations for adults over 50; more likely to be hospitalized for mental health and substance abuse related disorders; and more likely to be hospitalized for pneumonia. Within our region, rates of hospitalizations for Chronic Obstructive Pulmonary Disease, kidney and Urinary Tract Infection disorders are significantly higher in communities such as Lynn, Beverly, Gloucester and Peabody than for the state as a whole. There are also numerous census tracts in our catchment area in which both seniors and adults with disabilities are living in poverty with limited access to transportation or affordable food markets, and where health literacy rates are remarkably low. Essex County does not fare particularly well according to the Robert Woods Johnson Health Outcomes County Ranking Report released in Of the 14 counties in the Commonwealth, Essex County is ranked 8th in terms of overall health outcomes, and 9th and 11th respectively in terms of socio-demographic and clinical indicators of health. Essex County reflects rates very near or only slightly above the 50th percentile nationally on most of the model s health factor indicators. Live Well, Age Well NSES has a Memorandum of Understanding with the Healthy Living Center of Excellence at Elder Services of Merrimack Valley. This partnership allows NSES to work under the Commonwealth of Massachusetts chronic disease self-management program license promoting the Stanford Chronic Disease Self-Management programs (CDSMP). NSES has two Master trainers for CDSMP and one Master trainer for the Diabetes self-management program. NSES has two Master trainers for A Matter of Balance and three trainers for Powerful Tools for Caregivers. Falls, often a precursor to downward health spirals, are more frequent among adults over 40 in our service area compared to statewide rates. And, we estimate that more than 70,000 adults over 50 who self-identified as experiencing mobility barriers are currently facing mobility challenges often related to chronic diseases that preclude pursuit of healthier North Shore Elder Services Area Plan Page 13

15 lifestyles. NSES has established a Live Well, Age Well offering to present overviews of the various evidence based programs to community members. In addition to the programs mentioned above, Healthy Eating and exercise programs are explored. Northeast Elder Care Alliance In order to create better linkages between community services and medical providers and thus provide improved health outcomes for consumers, Northeast Elder Care Alliance (NECA) was created. NECA provides a bridge between the medical community and community services in managing elder health care. A social worker or elder care options counselor meets with referred patients at their home or doctor s office to help them plan for their long term service and supports. The alliance includes two Area Agencies on Aging, a medical practice, one health system, and a care management agency. At Your Side Medical Advocacy Program The goal of At Your Side is to help consumers better understand their medical issues and their doctors recommendations. Many elders are unable to manage chronic conditions due to factors such as age-related memory loss, low health literacy, mitigating factors such as lack of transportation to medical appointments, lack of money to obtain needed medications, or not fully understanding red flags or risk factors for their illness. As a result, continuity of care suffers, illnesses worsen, and healthcare becomes a greater challenge for all involved. No federal or state program has yet offered a way to meet this growing need. At Your Side provides trained volunteer advocates to help elders and their doctors by asking questions, working toward understandable answers, and evaluating all possible options, leading to improved care for the elders served. Over the Rainbow Coalition Over the Rainbow coordinates community groups to advocate for the well-being of lesbian, gay, bisexual and transgender (LGBT) seniors. NSES is the first organization on the North Shore to formally create a place for area LGBT seniors to socialize. Working with the House of the Seven Gables in Salem, Over the Rainbow and NSES created the first LGBT senior supper club on the North Shore, providing monthly Title IIIC dinners to nearly 50 attendees. NSES and the coalition also organized the area s first conference on LGBT Aging at Salem State University on March 16, This event, attended by more than 200, focused on interdisciplinary practice and policy for working with LGBT older adults and caregivers. The second annual conference was held this past March and the 2014 Conference is currently being planned for May North Shore Elder Services Area Plan Page 14

16 One Step at a Time Through the One Step at a Time program, the North Shore Center for Compulsive Hoarding and Cluttering at NSES provides a safe, supportive, and educational environment for individuals, their families, and their support systems. Hoarding is an outward manifestation of internal commotion and whether triggered by trauma, loss, or heredity, it is rarely resolved on its own. Through group work with peers, individuals, and family counseling, NSES assists in building a comprehensive plan to address hoarding behaviors and their underlying issues while teaching skills to help maintain and sustain progress. One Step at a Time offers Hoarding and Cluttering Support Groups, Support for Family and Friends, Comprehensive Assessments & Action Planning, Individual Counseling, In-home 1:1 treatment, and Therapeutic Support during Clean-ups. Essentials Closet Essentials originated from an idea to create a space for NSES staff to locate items free of charge for elders in need, in an emergency, or in urgent situations such as homelessness, fire or dire financial needs. NSES staff, family members and community members donate everything from pots and pans to personal items to blankets and towels. Essentials helps get the elder thru a difficult time and assists staff in finding Essential Items for immediate use with elders in need. Currently we have expanded to two donated storage spaces at Cranney Storage in Danvers and accept Essential furniture items. North Shore Elder Services Area Plan Page 15

17 Participant-Directed/Person-Centered Planning Providing options that promote consumer choice and direction while supporting the consumers decision is the backbone of all the programs supported by NSES. The ADRCGNS is instrumental in promoting this philosophy and as such, many of the programs listed below are available throughout the ADRCGNS area. ADRCGNS Cross Disability Training As a leadership agency of the Aging and Disability Resource Consortium of the Greater North Shore, Inc. (ADRCGNS), NSES is actively participating in the design and development of curricula focusing on cross disabilities awareness and sensitivity aimed at promoting persondriven planning and service delivery. Long Term Supports Services (LTSS) Coordinator Function Through the Commonwealth s One Care pilot program for the care of persons aged 21 through 64 who are dually eligible for Medicare and Medicaid, NSES, along with the leadership of the ADRCGNS, has created a LTSS coordinator function that reflects intensive cross-disability and aging-related training, expertise, and experience in decision support methodologies, and deep capacities around identifying and integrating diverse area resources. This role, unique in its comprehensive capacities and problem-solving approach, reflects the no wrong door philosophy; emphasis is on person-driven services and the ongoing interweaving of member services and resources that defines the ADRCGNS. Options Counseling The main purpose of Options Counseling is to help consumers identify and understand their needs and to assist them in making informed decisions about appropriate long-term service and support choices in the context of their personal needs, preferences, values, and individual circumstances. Options counseling is a free, short-term counseling service for elders, persons with disabilities, and their families, that provides consumers with information about long-term support services as well as consumer directed decision support to evaluate all available options. This model, based on decision support and consumer activation, is uniquely equipped to support consumers in assuming a greater role in their health management and planning for their long-term care. This change in behavior will be essential for individuals as they navigate new health care delivery systems. Mobility Links/Travel Counseling The greatest need documented in the 2013 Municipal Needs Assessment Report is the area of transportation. Assistance to get to medical appointments, more knowledge of public North Shore Elder Services Area Plan Page 16

18 transportation options, and expanded service hours are of major concern. Mobility Links provides consumers with the tools they need to make informed choices about transportation and mobility issues through decision support provided by trained travel counselors who are also trained options counselors. In this program, counselors, trained in decision support protocols, cross disabilities issues, and mobility management help individuals identify, choose and understand how to use both formal and informal community resources. Counselors are trained to listen for and help consumers recognize needs beyond just a ride and work with consumers to choose providers from the database which will best meet their unique requests. In addition to travel counseling, Mobility Links offers community education and outreach and an inventory of transportation, wellness, and health self-management supports covering the Greater North Shore. Travel Counseling suggests better quality of care and cost savings as it reduces medical appointment cancellations and/or no-shows. This results in better medical care in appropriate settings and reduces unnecessary emergency room visits and hospital re-admissions. The most recent addition to the Mobility Links program is the Kiosk for Living Well. Kiosk for Living Well NSES, as part of the ADRCGNS, has partnered with GLSS and their Kiosk for Living Well project, part of the broader Mobility Links mobility management initiative. Travel Advisors or counselors work with consumers in activities that support them in a wide array of self-directed options including memory and driving assessments, emergency and care transitions preparation, storytelling through virtual scrapbooking, and more. Kiosks are comprised of a variety of stations including: assistive touch-screen technology provided through, It s Never Too Late (IN2L) that offer a wide range of virtual exercise, travel, arts, story-telling and other experiences; digital self-assessment opportunities around issues such as health, memory, and even driving; health planning options; health self-management opportunities and workshops; scrapbooking; and on-site options, travel and employment counselors to whom the kiosk advisors make referrals as requested by consumers. The kiosk advisors are certified through trainings offered by North Shore Community College (NSCC) and GLSS. Core competencies developed through the training include motivational listening and other techniques for promoting consumer engagement; managing the virtual technology and other options offered at the kiosks; making referrals to on-site travel, employment, and options counselors as well as to other appropriate staff and programs in the community. The fundamental premise of the training is that the advisor is not there to fix problems but rather to support consumers as they develop problem-solving capacities. Advisors are trained to ensure that consumers remain in control as they articulate their dreams and life quality preferences; consumers receive and use North Shore Elder Services Area Plan Page 17

19 tools and resources to help realize their goals. Currently, kiosks are located at the Beverly Council on Aging, Danvers Council on Aging, and the Lynn Public Library. Improving Health Outcomes for L.I.F.E (IHO) The Improving Health Outcomes for L.I.F.E. program is designed for consumers most at risk for hospitalization and possible long-term care placement due to difficulty with the management of their health condition, medications, or access to medical appointments. The program targets isolated elders, low income elders, minority elders and socially isolated populations. The principal medical intervention is a monthly visit by a contracted Home health agency Registered Nurse. Care Managers and RNs conduct psycho social/financial assessments, assist with benefit applications, and provide phone and/or in-home follow up visits to support the consumer s care plan. Families and informal support networks are utilized to support elders in correct medication dosage and administration, reinforcing the importance of regular consistent medical care and education/training regarding chronic disease self-management. End of life planning is explored. Partnerships with the Mass College of Pharmacy and Salem State University are currently being explored. Elders are chosen based on identified problems with medication management, disease self-management, high hospital use, and /or failure to keep medical appointments. The program will be evaluated based on measurable reductions in preventable hospitalizations and emergency room visits, lower percentage of missed medical appointments, improved compliance with health protocols, and improved quality of life as determined by the consumer. In partnership with NSES and as an adjunct to the IHO for Life program, NSES provides office space and support staff to a medical practice that focuses on the frailest consumers in the North Shore area. One of the only physicians in the area to solely practice home based medicine, this practice has allowed over 150 elderly frail to remain in the community. North Shore Elder Services Area Plan Page 18

20 Elder Justice NSES Protective Service program NSES is one of 22 designated Protective Services agencies throughout the Commonwealth to respond to allegations of elder abuse. Elder abuse includes physical, emotional and sexual abuse, neglect by a caregiver, self-neglect and financial exploitation. The goal of protective services is to remedy or alleviate the abusive situation and to prevent the reoccurrence of abuse. Case workers are on-call 24 hours/day to respond to emergency reports. Services include: counseling, safety planning, family intervention, legal assistance, medical care, and housing, transportation, and homecare services. Consumer rights and wishes are respected with interventions geared towards the least restrictive environment. Freedom is more important than safety as long as a consumer is considered to have capacity, understands the risks they are choosing to accept and are not considered a threat to self or others. North Shore REACT North Shore REACT is a multi-disciplinary team of community based first responders, crisis, public safety and medical teams who serve elders (60+) on the North Shore. The goal of REACT is to work collaboratively to improve the safety and well-being of the elders in our communities. The core of our success is based on collaborative responses, increased and accurate communication and cross disciplinary education of one another. The outcome is fluid communication at all steps of intervention that provides the elders with appropriate outreach services and medical care while reducing duplicity. Once the collaboration began, the agencies were able to pool resources, open communication and offer proactive responses to at- risk elders in our communities. The result has been more appropriate, timely and successful interventions with elders as well as shared resources among involved agencies. This collaboration is innovative as it is truly multi-disciplinary driven. Most community collaborations are led by one agency, such as the police, and the agenda is set by the mission of that agency. REACT s agenda is developed by members, which results in agencies with different perspectives and priorities coming together to assess and solve a community problem. TRIAD Council The TRIAD Council is a partnership which includes the Sheriff and District Attorney of Essex County, the Danvers Police and Fire chiefs, the Council on Aging, NSES, other supportive services and seniors. The TRIAD meets quarterly with the goal of improving the safety and quality of life for seniors. North Shore Elder Services Area Plan Page 19