Stories

Deepdale CARES NORC program

Community

Understanding the Community

Staying Vibrant

When Deepdale CARES was still in the design stage, Samuel Field Y staff formed an ad hoc committee of core stakeholders in the community and in Deepdale Gardens, ran a series of on-site focus groups with senior residents and conducted home-based interviews with the frail elderly. Their collected insights became the basis of a needs assessment distributed to every resident of the Deepdale Gardens Cooperative.

While the results provided the basis for an initial package of services, a responsive project doesn’t stop with one survey – the task of finding out what a community looks like and what residents want is ongoing. To stay focused on a moving target, the needs assessment is repeated at Deepdale every year.

The Deepdale CARES Advisory Board is another essential tool for listening to, and learning about, the community. Residents make up about half its 22-person membership, with the remainder including representatives of the housing and health system entities, civic associations and local business, senior service providers, religious leaders, elected officials, and the Samuel Field Y.

“We are the eyes and ears of the community,” said Stanley Levitt, a resident of Deepdale for more than four decades and an advisory board member.

At a typical monthly meeting, Deepdale CARES program director Laura Greenblatt, LCSW, presents a case that captures the scope of the in-home social work and nursing services that are available. “We want board members to understand how the program works. These are our representatives in the community, and our best advocates. If they are cognizant of how we can help, they can refer people to us,” said Ms. Greenblatt.

Much of the rest of the advisory board meeting is devoted to programming. Staff always asks advisory board members, “How are we doing? What else would you like to see happen at the NORC? What are you hearing from your neighbors?”

The answers have helped Deepdale CARES to evolve and meet the changing needs. For example:

• Nursing services have been increased as residents who were in their early 80s when the NORC program was launched move into their late 80s. (Every other age group is following the same trajectory, of course.)
• After the new Medicare prescription drug benefit was enacted, seniors asked for, and got, guidance to use it effectively.
• A stress management group was designed after social workers recognized stress among the residents.
• Available exercise options became too vigorous for some of the older residents, and chair yoga was added to the palette.

With each challenge came a response that revealed Deepdale’s nimble structure. “Just doing what you’ve always been doing is not how a program stays vibrant,” said the Y's Karen Schwab. “NORCs are not static at all. Other populations and other needs keep emerging.” Continued...

Partnerships

Partnering with the Community

A Committed Housing Partner

When New York City announced its intention to provide a new pool of funding for NORC programs, the Samuel Field Y identified Deepdale as a potential site. Staff made a presentation to the Deepdale Gardens coop board of directors about its existing Clearview Gardens project, and then scheduled a series of follow-up meetings to address questions as they surfaced. “We did a hard sell about why it would be advantageous to have a NORC program,” said the Y’s Karen Schwab.

The coop board already understood some of the challenges its elderly residents were facing, and they knew those problems had consequences for the entire apartment complex. They had heard complaints from unhappy neighbors, knew that seniors regularly called the management office when they did not know where else to go for help, and paid legal fees when eviction became necessary.

But the board also recognized that the city’s requirement for matching funds meant it would have to make a financial commitment from the outset. Ultimately, its decision to do so reflected more than just altruism. “It is not just that the board is so interested in being wonderfully helpful to elders,” said Ms. Schwab. “They are looking at the economics. They don’t have the staff or the knowledge base to manage some of the challenges faced by an aging population.”

By all accounts, the coop has been a willing partner for many years. Keeping residents safe is in everyone’s interest, and the management office is well aware that it doesn’t have the knowledge or staffing to deal effectively with a resident who wanders or forgets to pay bills. Deepdale CARES offers training at luncheons and other forums to help management know how to identify isolated and vulnerable seniors, and when to alert program staff to potential problems. Maintenance personnel learn to be alert to signs of trouble when they are in apartments making home repairs.

But if the NORC program is an asset to the coop, no one at Deepdale CARES takes its annual contribution of $25,000 – plus other in-kind services -- for granted. Recognizing that board members keep changing, and priorities can shift at any time, “we have to constantly reeducate the board about what a NORC program is, what it does and how it is helpful,” said Ms. Schwab. “I don’t make the assumption that they are willing to write me that check every year.”

Nursing Services: From a Community Benefit to a Budget Line Item

North Shore-Long Island Jewish Health System enthusiastically accepted the Samuel Field Y’s invitation to join as a partner to Deepdale CARES. “Our health system has been very involved in integrating and coordinating care to the elderly,” said North Shore-LIJ's Lynda Cooper. “We thought it was a terrific opportunity to become known in the community as an innovative health provider.”

Traditional reimbursement streams rarely cover the kind of long-term, home-based nursing that North Shore-LIJ’s community nurse now provides in the Deepdale NORC program. “No one pays to have someone come in to help a resident manage chronic illnesses, keep the home safe, and help families understand what they can do,” said Ms. Cooper.

But hospitals are required to provide some level of non-reimbursable services, known as “community benefits,” to maintain their tax-exempt status, and that is what North Shore-LIJ intended by covering nursing services two days a week without charge. “We are committed to giving back to the community that patronizes us with a certain amount of activity that no one pays for,” said Ms. Cooper.

The partnership with Deepdale CARES, which Ms. Cooper called “a great fit,” also gave the health system an opportunity to experiment with innovative programming; to conduct research to learn how best to promote good health among seniors living in the community; and to inform some of its other activities involving elderly populations.

But over time, and as other NORC programs also requested nursing services, North Shore-LIJ decided the stable funding streams for nursing was needed. It was a matter not only of economics, but of sustainable program design. “The margins of health care have changed over the years, and there is a lot of competition for that margin,” said Ms. Cooper. “Nursing is critical to NORC programs and we felt that as a principle in their development, it has to be paid for.”

At Deepdale CARES, the budget transition occurred gradually. In 2004, through the NORC Health Care Linkage Project, the United Hospital Fund and the New York Community Trust provided funding for two additional days of nursing service to focus on falls prevention, while North Shore-LIJ continued to underwrite the other two days. Two years later, the Samuel Field Y was able to assume the full costs of nursing through its public sector grants. Continued...

Implementation

Designing and Implementing Your Program

The Social Worker/Nurse Team

Case management is a core service at Deepdale CARES, with three licensed clinical social workers available to make comprehensive client assessments, develop service plans in partnership with the resident and family members, coordinate services with other agencies, and provide various forms of counseling, advocacy, and benefits assistance.

Equally important is healthcare management. Four days a week, a nurse is on-site at the NORC program, helping to manage chronic health conditions, monitor medication use, provide basic screening, assess the home for safety, and communicate with physicians. Dale Chaikin, RN, has been the community health nurse since the program was launched. Through the Samuel Field Y, the full cost of nursing is included in the Deepdale CARES budget, although Ms. Chaikin remains on the payroll of the North Shore-Long Island Jewish Health System.

But what makes Deepdale CARES truly unique is the close working relationship between the social workers and the nurse. The operative attitude: “It is not my client, or your client, but our client.”

Many initial home visits are made in tandem. True partners, each professional brings a unique set of skills and experience to the visit, but no artificial boundaries divide them. The social worker may engage the client in a discussion about family support while the nurse walks into the bathroom to see whether safety bars have been installed. “Our eyes go to different places,” said Ms. Chaikin. “But we respect each other and understand the importance of approaching every home as a team.”

Seniors seem more willing to open their doors when a nurse and social worker approach together. While many residents are familiar and comfortable with the nursing resource, a social worker’s agenda can seem a bit less transparent, and sometimes raises fears that a resident’s troubles will be “reported” to family members or a doctor. Sending a clear message that the client is in charge also helps to alleviate that fear. “The clients are the ones who dictate how the case goes,” said Ms. Chaikin. “They tell us who we can talk to and who we can’t.”

The Deepdale nurse and social workers also communicate effectively with hospital discharge planners within North Shore-LIJ’s Health System, ensuring a continuum of care. When a resident is being discharged, NORC program staff finds out about it, and learns how long Medicare-funded home care will be in place. “We meet with hospital social workers and home care nurses so that they can update us on the client and we can let them know what our services are,” said Ms. Chaikin. “The hospital is thrilled to know that care will remain in place after a patient is discharged.”

Advocating for Better Transportation

Public transportation options are limited in northeast Queens, especially for residents who can not easily walk to bus stops, or transfer from one bus to another. Resident surveys and comments from Advisory Council members underscored the vital need for better transportation to medical appointments, shopping, and local educational and recreational activities.

One option is Access-a-Ride, a Metropolitan Transit Authority service for New York City residents with disabilities who can not use the public transportation system. With advance reservations, Access-a-Ride will provide shared, door-to-door service 24 hours a day for the usual price of a subway or bus.

There is just one catch: the program operates only within the five boroughs of the city. But Deepdale sits right on the city’s border with Nassau County, and many residents see physicians on the other side of that dividing line.

The residents of Deepdale decided to speak out about the impact on their lives, boarding a bus chartered by the Samuel Field Y to make the three-hour journey to Albany, where they testified in favor of changing the geographical restriction.

“As a professional, I can talk until I’m blue in the face about allowing Access-a-Ride to cross county lines,” said the Y's Karen Schwab. “But when we have a senior who is 85 and stands up before the legislature and says, ‘I can’t get to my doctor any longer because he has moved across the county border and I can’t afford the $25 taxi,’ that has a very different impact.”

Their compelling testimony helped get a bill passed by both houses of the legislature, but it was vetoed by the governor. Assemblyman Mark Weprin, who represents the district that includes Deepdale, intends to introduce a new bill at the next legislative session. Meanwhile, the seniors have learned a lot about what it takes to be heard, an essential skill as they testify in favor of renewing public NORC program funding. Their activism has also helped to raise awareness in the surrounding community about transportation challenges, making it easier to attract donations for other solutions.

For now, the Samuel Field Y is meeting many of the transportation needs of Deepdale residents with a van service funded by New York City’s Department for the Aging. The Deepdale CARES office manager works with the Y’s transportation coordinator to make that happen. Private donations are used to pay for supplementary taxi services, which are available on an as-needed basis.

Preventing Falls

Social work and nursing staff recognized falls as a serious problem within the Deepdale community. Data from the North Shore University Hospital confirmed that: in 2002, 80% of emergency room visits by people 65 or older living within the Deepdale zip code were due to falls-related injuries.

NORC program staff were already trying to identify risk factors for falls in residents’ homes, but they had no mechanism for communicating with physicians about the problem. The NORC Health Care Linkage Project, funded by the United Hospital Fund and the New York Community Trust to promote closer connections between NORC programs and health care providers, offered an opportunity to take on this issue.

“Our underlying goal was to open up communication between patients and doctors,” said Ms. Schwab of the Samuel Field Y. “We chose falls prevention as the methodology to do that.”

Ms. Chaikin, the Deepdale community nurse, added: “We knew if we could establish relationships with physicians on the subject of falls, it would transfer to other areas and help us manage the client.”

Planning the project

Community partners were involved as the falls prevention project was planned. In particular the North Shore/Long Island Jewish Health System, the health care partner, contributed its expertise through its Geriatric Committee, its Osteoporoses Task Force, and its home care network.

During the planning phase of its falls prevention project, Deepdale CARES staff:

• Screened residents and concluded that almost two-thirds of those responding were at risk for falls.
• Held focus groups with residents, which revealed that they were not routinely assessed for falls by their physicians, and that they generally reported a fall only if they suspected a broken bone. The focus groups also suggested seniors were not being properly trained in the use of assistive devices, such as canes.
• Held focus groups for physicians, who stressed the importance of a streamlined process for communicating with NORC program staff. They were concerned about being overburdened with paperwork and preferred to exchange information via fax.
• Reviewed the tools available to assess risks for falling and concluded that a questionnaire developed by the John A. Hartford Institute for Geriatric Nursing created the fullest portrait of vulnerabilities.
• Identified diagnoses that may entitle patients to receive reimbursable outpatient physical therapy.

Implementing the Project

Building on that information, Deepdale CARES staff implemented a falls prevention protocol that:

• Administered the Hartford Institute Falls Assessment Tool in the homes of 93 residents considered likely to be at risk. Many of these residents were identified by the Deepdale CARES nurse; staff, family members, neighbors, and primary care doctors suggested other potential participants. The in-home assessment allowed staff to evaluate the physical environment at the same time each resident was surveyed.
• Distributed information to community physicians about Deepdale CARES and the falls intervention program.
• Developed a care plan for each resident considered at risk.
• Faxed the assessment results and suggestions for care and referrals to participating physicians.
• Received back the care plan/referral form from physicians, who had an opportunity to request any of the following services for their patients, including: home safety assessments, medication monitoring, blood pressure monitoring, social work evaluations, and referrals or physical therapy and adaptive equipment.
• Provided follow-up to keep residents, physicians, and other service providers current on client progress.
• Conducted community education and distributed materials to help seniors recognize the risk factors for falls and the importance of good communication with physicians. Physicians received magnets with NORC program contact information on it.
• Reassessed participants to determine the program’s impact on their risk for falls and their communication with providers. Continued...

Evaluation

Evaluating Projects of a NORC Program

Preventing Falls: Evaluating the Project and Lessons Learned

Almost from the moment it began to design its falls prevention program, Deepdale CARES also planned for its evaluation. Guided by the logic model, staff laid out each step of the falls prevention protocol, which was intended to meet twin goals:

Clinical goal: Decrease the risk factors associated with falls.

Structural goal: Increase communication and cooperation between NORC program staff and local primary care physicians in private practice.

Keeping Records

A work plan listed key activities, the dates they were started and completed, desired outcomes, and the person responsible for making sure that each step happened. At regularly scheduled meetings, staff reviewed the plan to make sure the work was on target.

NORC program staff also created a Clinical Tracking List to follow client progress. This provided a simple and consistent way to collect data.

By assessing 93 older residents before the prevention protocol was in place, Deepdale CARES had baseline data on which to build the evaluation. Baseline information included on the Tracking List included the client name or record number; the date the initial assessment was conducted; the assessment score; and whether the individual was considered at risk.

After the initial assessment was completed and a care plan had been developed, the Tracking List was used to record each recommendation in the care plan; the intended follow-up by NORC program staff, and information on compliance and further follow-up.

Findings

Initial survey results indicated that 80% of the participants were at risk for falls. Risk factors included a history of falls; use of certain medications; inability to walk independently; a history of emotional problems; sensory deficits; and impaired judgment.

When the same residents were reassessed six months after the falls prevention protocol was in place, 60% of them were found to be at risk, a significant decline.

Improvements in patent-provider communication proved somewhat harder to measure, but 29 community physicians requested one or more follow-up services for their patients and physicians initiated a significant amount of communication about falls with NORC program staff.

Staff concluded that the falls prevention program helped to put risk-reduction strategies into routine medical practice, and successfully involved physicians in planning for the care of their patients. But along the way, they encountered a few surprises.

Lessons Learned

“In our naiveté we thought the majority of seniors in Deepdale would have a lot of doctors in common, but that was wrong,” said the Y's Karen Schwab. That meant a much larger outreach effort was required to involve all of the community physicians who served participating residents.

The time constraints on busy physicians proved to be another challenge, with doctors repeatedly cancelling the breakfast meetings they had scheduled to talk about the falls prevention program. Eventually, NORC program staff discovered it was more useful to speak with the nurse in the office, who would then brief the doctor.

Another unexpected outcome was that patients became more empowered to talk to their physicians. “Our emphasis had been on promoting communication between doctors and our staff, but we found out there was a lot the clients needed to be doing, too,” said the Deepdale nurse Dale Chaikin.

Educating seniors about how to talk to their doctors became part of the community education piece of the project. “Seniors told us they were realizing they needed to go into the doctor’s offices with questions written down and with someone to hear what the doctors were saying,” says Ms. Chaikin. “ They were really learning how to be a part of the process.” Continued...

Sustainability

Sustaining Your Program

A Friendly Community for All

Along with stable funding sources, a sustainable NORC program is one that keeps drawing in fresh blood and building new relationships, as it gradually becomes woven into the fabric of the community.

Intergenerational programming is one of the tools Deepdale CARES uses to build broad-based interest. Most of its activities are open to anyone, regardless of age – younger people are welcome to watch movies and participate in exercise classes and other scheduled events. A flea market draws in residents throughout the apartment complex. And students struggling with reading, math, and English as a second language have turned to senior residents for tutoring.

“We felt that for the coop board to maintain its commitment, we needed to engage more of the community,” said the Y's Karen Schwab. “We look for opportunities to accommodate younger people.”

The goal is also to foster appreciation among middle-aged people for the value of the NORC program in their midst. “Our only hope of maintaining the NORC program is to get people who are now in their 50s interested, because they will eventually be in their 60s,” said Ms. Schwab. “The next generation needs to know what a NORC is even if they don’t need services yet.”

Reaching out to the neighborhood merchants and other community institutions is another way Deepdale CARES works at becoming known, and having an enduring impact. Senior art projects are displayed in the local bank. The supermarket and bagel shop carry flyers about NORC program activities. And the library stocks books that the book group has selected for its next reading.

“We work hard to create relationships, that’s part of how we raise awareness of the NORC program,” said Ms. Schwab. “Awareness is essential because you never know where your support is going to come from. I’m uncomfortable letting it come by chance, because by chance that support could end.”

Ultimately, the idea is for the NORC program to become embedded in the culture of the community, and to influence the way in which people relate to one another. “NORC programs change community and create community,” said Ms. Schwab. “If you have a friendly community, where everyone cares about everyone, seniors will be part of it. The NORC program can help make that happen.”

Stanley Levitt, 72, has seen that first-hand. A Deepdale resident since 1966, he barely knew his neighbors in the years before the NORC program was launched. “Now, it is like the good old days where you knew everyone on the block,” he said. “When you walk down the street it isn’t just hello, it’s hello by name. People recognize one another and are opening up.”

As people develop connections to their neighbors, they become more interested in them, and eventually develop a stronger sense of responsibility for them. At Deepdale, the NORC program professional staff helps guide that process, providing a structure so that people understand what they can do when they see a neighbor in need. But it is the residents themselves who do the work.

“Aging doesn’t stop at 5:00 or on weekends, when we are not here,” said Dale Chaikin, the community nurse. “We want to give people the tools to help each other.” As new ways of living are embedded into the Deepdale community, they become self-sustaining. It is a slow process, but over time norms can change. Specific services may not always be available, staff members may turn over, residents may move or die, but the strength of a caring community endures.