Designing and Implementing Your Program
Strengthening Health Care Services
The Lincoln Square Neighborhood Center’s first NORC program proposal to the city was designed with a strong social work focus, and an emphasis on improving access to entitlement programs. But soon after getting off the ground in 2000, staff discovered another, more basic, need.
You don’t know what you don’t know
Despite Lincoln Square’s strong connections to the community, the most fragile elders had been overlooked in the initial planning for a NORC program. The gap for them -- indeed, the chasm – was access to health care, but mobility restrictions had cut them off from the forums created to articulate the needs of older adults.
That realization dawned as residents began venturing into the lobby for free health screenings, only to be urged to get to the hospital immediately. Staff discovered that less than one-third of seniors in the Lincoln Square community had a regular source of health care – most were using clinics or hospital emergency rooms episodically. Many had expired medications or were taking drugs with potentially dangerous interactions. In the program’s early days, the part-time nurse – on board just four hours a day, three days a week – intervened in 40 potentially life-threatening health care crises.
Shaping a response
Health services were immediately moved to the top of the priority list, giving Lincoln Square an urgent reason to strengthen its fledgling partnership with Roosevelt Hospital. Staff from the two institutions held a series of planning meetings to hammer out a response to the newly discovered health care crisis.
In 2001, the United Hospital Fund provided $50,000 towards the cost of a full-time nurse, supplementing the resources Roosevelt had committed. By tracking that nurse’s activities, Lincoln Square staff was able to show that seniors accessed on-site health care services 1,200 times in the first eight months of funding. Staff also documented 197 health promotion activities, including exercise classes, health education workshops, health screenings, support groups, and health fairs.
“Having someone on site five days a week creates a very different model,” says Anne Moses, the NORC program’s champion at Roosevelt. “That person becomes part of the care team. That’s very different from someone who just drops in.”
The health care component of the program has only grown in subsequent years:
Connections to primary care: An early emphasis on connecting people to primary care physicians at Roosevelt Hospital meant that by 2007, 95% of senior participants in the NORC program had a primary care provider. In 2000, only 20% had one.
Tackling hypertension: The extent of uncontrolled hypertension in the community led Roosevelt to create Healthy Living for a Healthy Heart, a nine-week intervention that provided assessment, education, and activities for Lincoln Square seniors. The hospital put together a team that included a physician, a nutritionist, an exercise physiologist, a health educator, and a nurse to develop a multidisciplinary approach that resulted in dramatic – and documented – improvements in blood pressure.
Emergency Department report: Lincoln Square and Roosevelt created a simple strategy for informing the neighborhood center’s on-site nurse of any NORC program resident who was admitted the previous day to Roosevelt’s Emergency Department. The nurse then provides follow-up, visiting seniors in the hospital or calling them when they return home, to assess their health care needs and determine what other support may be appropriate.
This initiative was funded through the United Hospital Fund’s NORC-Health Care Linkage Project, established in collaboration with the New York Community Trust. The process proved easy to implement, and has been working well. So well, in fact, that Beth Israel Medical Center, a sister hospital within the same large health system, now uses the same approach.
Safer medications: MyMeds, a medication safety project, was also developed under the Linkage Project. The idea is to create a profile of all the medications used by older adults, to house this at local pharmacies and to make it available to Emergency Department physicians on request.
An evaluation showed that most Roosevelt doctors have not asked for the profiles, which have to be faxed to them. Staff believes immediate electronic access would be more useful, and may eventually reconfigure MyMeds to accommodate that. Meanwhile, the project has had other benefits:
- Each senior has consolidated prescriptions in a single pharmacy, which improves the continuity of care and gives pharmacy partners opportunities to intervene to prevent drug interactions.
- The NORC nurse now has accurate and up-to-date medication profiles available for each client.
- Beth Israel Medical Center found MyMeds idea promising enough to develop a pilot test of its own.
All of this took time and resources – but first, it took information. Neighborhood center staffers stuck their toes in the water with early plans for a NORC program, based on what they thought they knew about the needs of the residents. They gained experience, they learned more, they collected data, and they discovered gaps.
Then, they used all of that to inform their practice, revise their early approach and develop new strategies, some of which are now being replicated by others.
Using Data to Guide Program Development
The AdvantAge Initiative
In 2003, the Lincoln Square Neighborhood Center joined nine other sites across the country as participants in the foundation-funded AdvantAge Initiative. The initiative describes its mission as helping to build “elder-friendly communities that are prepared to meet the needs and nurture the aspirations of older adults.” At the heart of the project was a comprehensive telephone survey of older adults in each of the selected communities that focused on:
- Basic needs for housing and security.
- Maintenance of physical and mental health.
- Independence for frail, disabled, and homebound elderly.
- Opportunities for social and civic engagement.
Lincoln Square staff laid the groundwork for participation in that survey by alerting them to the interviewer’s call; explaining the value of collecting information; and offering coupons to local stores for their participation. Without that preparation, suspicion would most likely have trumped cooperation. “You can’t overestimate the need to have someone connected with the community make the introductions,” said Stephanie Pinder, the neighborhood center’s executive director.
The AdvantAge Initiative’s 2003 “data snapshot” of the Lincoln Square neighborhood on Manhattan’s Upper West Side revealed three compelling facts:
- Fourteen percent of the senior respondents skipped meals or went to bed hungry because they did not have enough money for food.
- More than one-quarter of respondents rated the safety of their neighborhood as either “fair” or “poor.”
- Fifty-six percent reported feeling depressed or anxious and many who needed mental health services said they were not available.
The data underscored the observation that Lincoln Square staff later made in a report to funders: “The more you do, the more you uncover and need to do.”
Social workers were not completely surprised by the findings. They had seen how older adults descended on the congregate lunch, especially on Mondays because no food was served over the weekend. They had heard reports of drug dealing in the buildings and knew that some of their clients were hostages in their own homes. And they were aware that many of the people they served struggled with depression and anxiety.
But having data to support anecdotal observation changed the discussion. “The data confirmed our own experiences and allowed us to move the agenda forward,” said Ms. Pinder. Program staff brought the findings to the NORC Advisory Council, whose members were shocked by some of the hard numbers. They insisted on moving as quickly as possible on a three-part plan of attack: to confront hunger; address safety and security; and improve mental health.
The Advisory Council became the sounding board and guiding hand, with quarterly meetings where Lincoln Square staff reported on recent activities, fielded questions, and considered new ideas. Through their own web of connections, Council members also helped to bring in new partners and to mobilize new resources to meet the needs. Continued...