The Changing Landscape of Aging Services

Health care reform, market pressures and demographic shift are changing the familiar landscape of Long Term Services and Supports, requiring consumers, healthcare providers and community based organizations to adapt. How can stakeholders shape new policies and service delivery models that are person-centered? How will providers of health and supportive services interact in this new landscape? How can community based organizations engage to become the change? These questions might best be answered through an exploration of possibilities, innovation and recent developments.


Collaborative Recommendations re: Homeless Older Adults

July 25, 2017  – For the past 9 months SSC has partnered with Health Care Services Agency to convene meetings with Alameda Health System and the other systems, agencies and CBOs. We recently convened a facilitated discussion focused on homeless older adults and encampments. Here are some of the take-aways from that discussion and follow-up work.

Health Care for the Homeless estimates that 33% of the homeless people that their street medicine teams treated last year were over age 55. People ages 55+ account for 27% of the HomeStretch registry.

Older adults may present an additional set of factors that, if ignored, set them up to “fall through the cracks”. These include needing assistance with activities of daily living, cognitive deficits, multiple medications, grief and loss, multiple EMS contacts and hospital admissions, and the potential to reunite with family caregivers.

Solutions identified include:

  • On-call access to geriatric and dementia expertise, as well as training in working effectively with people with cognitive impairment, for the staff of housing resource centers, shelters, Permanent Supportive Housing, and emergency services)
  • Identify and implement funding mechanisms to cover post-acute transitional care beyond 30 days when needed.
  • Provide public health, nursing and hygiene services at homeless encampments.
  • Expedite proactive IHSS eligibility to qualify people for housing or reunify with family caregivers (Adult & Aging Services is starting up a pilot to do just that).
  • Reconfigure shelters so that they are viable options for older adults.
  • Develop relationships and systematic connections between case managers and housing services to facilitate continuity of care through transitions and help older adults stay in long-term housing.

The full report will be out soon. The recommendations are being shared with the multiple workgroups within county agencies and cities that are focusing on addressing homelessness.

Home Stretch Launch

July 31, 2016 – EveryOne Home has launched Home Stretch, Alameda County’s collaborative strategy to prioritize permanent supportive housing opportunities to homeless and disabled people with the highest needs in order to maximize the impact that this housing can have in ending homelessness. Home Stretch will establish a county-wide registry of people who are homeless and disabled, and a centralized process for linking high need individuals and households with permanent supportive housing opportunities. It also will provide housing navigation services for people prioritized for permanent supportive housing. For more information, go to:

EveryOne Home will be providing trainings on referring, housing match readiness and Home Stretch HMIS entry in the coming months. To put your name on the list to receive training information and dates, click here.

Hotel Oakland Village

July 6, 2016 – Hotel Oakland Village is a new approach to senior living. Find out how this community makes a positive impact for its residents in Oakland. Click the video below to learn more about the project:

San Mateo’s Secret Sauce

May 31, 2016 – In a recent conference call convening of Regional Coalitions in California sponsored by The SCAN Foundation, Maya Altman from Health Plan of San Mateo gave a presentation about HPSM’s Community Care Settings Pilot. The Pilot is an intensive care management program that leverages IHSS, CBAS, Behavioral Health, community-based services, housing and housing services. The Pilot is proving remarkably effective in stabilizing high utilizers and helping them to migrate out of or avoid SNF/LTC Facility residency and homelessness.

This extremely collaborative Pilot is overseen by a multi-disciplinary core group. The program employs extensive face-to- face case management, purchase of services, and a phased approach. One of the Pilot’s most unique elements is its collaboration with Brilliant Corners, an organization that not only develops housing but provides a spectrum of person-centered services to help individuals find and maintain housing.

HPSM is a County Organized Health Plan that is the sole Medi-Cal Managed Care/Cal MediConnect plan for Duals and Medi-Cal- only residents of the county. While San Mateo is differently organized than Alameda County, the Community Care Settings Pilot offers operational and program delivery models that may be relevant to our county. To learn more, click here for Ms. Altman’s presentation, and click here for a Profile of the Pilot by Center for Health Care Strategies.

Village & Wellness Connection

February 16, 2016 – Last week, Family Bridges and the Hotel Oakland launched a new health and wellness program for senior residents of the Hotel Oakland, a historic building in downtown Oakland that is a residential community for 400 low-income seniors. The Village and Wellness Connection will promote healthy aging by encouraging seniors to become proactive about their physical and emotional well-being. By identifying and treating problems before they lead to expensive trips to the emergency room, the Village Connection aims to reduce hospitalizations and health care costs.

Family Bridges is well known for their Hong Fook Adult Day Health Care Centers, located in downtown Oakland around the corner from Hotel Oakland. The Hong Fook Centers help frail elderly and adults with disabilities regain their ability to live independently and ease the need for family care by providing health services and therapeutic activities in a safe and supportive environment.

The program is an expansion of the Hotel Oakland Village, a social outreach and engagement program started in 2011 to reduce isolation among senior residents. The new Village Connection will provide participating seniors with a physical and social/emotional assessment, then help each person develop a long-term health plan. If the senior wishes, the confidential plan can include input from family members, physicians and caregivers. The plan adjusts as a person aging and his/her needs change.

The Village Connection’s Wellness Director will review seniors’ medications for incompatibilities, and each individual’s plan will support dietary guidelines, memory care activities, exercise, fall prevention and emotional well-being. The Director acts as a point person for coordinating each senior’s care, working with the individual’s support network and when needed with hospitals, discharge planners and transitional care providers. All with the goal of helping residents avoid institutionalization and age in place.

Recent Developments

What if Health Care Providers Could Diagnose Food Insecurity!

February 7, 2018 – The Food Research & Action Center and AARP Foundation have released a free, online course to educate health care and community-based providers around the country about the extent of senior hunger and the solutions that exist to solve it. Titled “Screen & Intervene: Addressing Food Insecurity Among Older Adults,” the course provides training on how to screen patients 50 and older for food insecurity, and information on how to connect food-insecure patients to key nutrition resources, including the Supplemental Nutrition Assistance Program (known as CalFresh in California). Nationally, 2.8 million households with at least one adult age 65 or older struggled against hunger in 2016. Click here for more information.  Register for the course at

Congress Passes Bipartisan Legislation
on Family Caregiving

February 6, 2018 – The Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers passed Congress with bipartisan support and has been signed into law. A broad coalition of aging and disability organizations advocated for passage, working closely with Sens. Collins (R-ME) and Baldwin (D-WI) and Reps. Harper (R-MS) and Castor (D-FL).

The legislation requires the Secretary of Health and Human Services to develop, maintain, and update a strategy to recognize and support family caregivers. An advisory council will be formed to develop the strategy with public input. The development of the initial strategy will take up to 18 months, followed by biennial updates. Click here to read the text of RAISE ACT.

Dementia Resource Guides

January 21, 2018 – The CMS Medicare-Medicaid Coordination Office (MMCO) has three new resource guides intended to support providers and health plans serving older adults and caregivers. These two resource guides, one created for caregivers and the other for healthcare professionals, include training and toolkits, fact sheets, publications, and information resources from various organizations and health plans.

To view these guides, click here.

Gerontologist Study on Adult Day Programs 

September 6, 2017 – A new article in Gerontologist, The Effect of Adult Day Program Attendance on Emergency Room Registrations, Hospital Admissions, and Days in Hospital: A Propensity-Matching Study, looked at people age 65+ who also had home care. It reports that Adult Day Program attendees had significantly lower rates of emergency room registrations, hospital admissions, and days in hospitals for attendees, compared to matched non-attendees.

The findings replicate and extend results from previous research that reported a decreased reliance on costly health care services by seniors who attend adult day programs. Click here to go to the article.

Medicare Begins Covering Care Planning for Cognitive Impairments

May 22, 2017 – As of January 1, 2017, Medicare will now pay for care planning services for beneficiaries experiencing cognitive impairment, including Alzheimer’s disease. Under new billing code G0505, health care providers can be reimbursed for providing a comprehensive set of care planning services that includes a cognition-based evaluation, functional assessment, and caregiver identification and interview. Click here for information on the new billing code from the Alzheimer’s Association, and click here to go to the Alzheimer’s Association page on approved cognitive assessment tools.

State Wins CalFresh Waivers to Benefit Seniors

April 21, 2017 – The USDA has approved two waiver requests submitted by California’s Department of Social Services to streamline enrollment and increase benefits for CalFresh households with seniors and/or disabled members.

The Elderly Simplified Application Project (ESAP) and Standard Medical Deduction (SMD) demonstration project will be implemented simultaneously beginning October 1, 2017. The ESAP is designed to simplify the application and recertification processes by making three significant changes to the application and recertification requirements for households with only elderly (age 60 or older) and/or disabled household members with no earned income. The SMD simplifies the CalFresh application process for CalFresh by reducing the paperwork burden and the time that eligibility workers must spend verifying every expense.

These changes to can help increase older adult participation in CalFresh.

Click here to go to California Food Policy Advocate’s summary of the new waivers and download their fact sheet and report.

Medicare Regulations Regarding Physicians & Teams

December 27, 2016 – On Jan. 1 2017 a new set of Medicare regulations will go into effect that will compensate physicians for legwork involved in working in teams — including nurses, social workers and psychiatrists — to improve care for “high need” patients with illnesses such as diabetes, heart failure and hypertension. The new rules will also reward efforts to ensure that seniors receive effective treatments for conditions such as anxiety or depression. Click here to read the California Healthline article on this new development.

Study Identifies Keys to LTSS Integration Success

May 27, 2016 – The Long Term Quality Alliance recently released a study looking at the effectiveness of long-term services and support integration among five health plans in different states. The Health Plan of San Mateo took part in the study. The study set out to determine whether integrating medical, behavioral health and LTSS benefits in a single capitated program can achieve better outcomes for a high-cost, high-risk population.

High Level Conclusions: several activities seem to matter the most in affecting outcomes for members and overall costs of care:

  • Anticipating needs and providing enough support in the home and community early enough reduce the risk of an inappropriate use of ER services, hospitalization, or nursing home admission.
  • Arranging for critical supports and services (e.g., housing, employment, personal assistance, medication management) enable medical and behavioral health professionals to earn the trust of the member, address health needs, and elicit positive behavioral responses.
  • Communication, coordination, and a single point of accountability can eliminate the conflicts, gaps, and inconsistencies in treatment that arise when multiple professionals perform their work in individual siloes. When multiple professionals from different siloes interact with an individual, this in fact interferes with a successful response to treatment.
  • Supporting members through transitions of care, particularly in moving from more intensive, higher cost to less-intensive, lower-cost settings, reduces the risk of readmission and relapse.
  • Care management is at the heart of what integrated programs do to integrate LTSS and medical care and is key to achieving results.

The study also concluded that integration of medical care and LTSS is difficult to achieve, and that statutory and regulatory reforms affecting financing and the siloed nature of the service delivery system are needed to remove barriers that make integration difficult. Here is a link to the study:

New Mandate to Involve Caregivers in Hospital Discharge

January 4, 2016 – Beginning in January 2016, family caregivers could have more support for their role in helping patients discharged from the hospital. A new California law, SB 675, requires hospital staffers to involve family caregivers during the hospitalization and discharge process. The intent is to improve patients’ overall health and reduce their chances of readmission.

Sponsored by State Senator Carol Liu, the law mandates that hospitals give patients an opportunity to identify a caregiver; notify that caregiver when the patient is to be discharged; and provide information and instruction on the patient’s needs and medications following the hospitalization. Hospitals still must follow privacy laws and aren’t required to release information if the patient doesn’t give consent.

California is one of 18 states to pass such laws during the past two years, part of a growing awareness among policymakers and legislators that family caregivers play an important role during and after a patient’s hospitalization.

Managed Care 101

The SCAN Foundation’s January 8, 2013 webinar helped community-based service providers and advocates understand the fundamentals of managed care, and what is involved in integrating long-term services and supports into a managed care model. The Webinar will orient you to the brave new world of managed care, and is an essential start in preparing your organization for the 2014 launch of the Coordinated Care Initiative in Alameda County.

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