The Community Services Agency, a non-profit social-services safety net for the needy in Los Altos, Los Altos Hills and Mountain View, has expanded its Case Management Program to help seniors over 60 maintain their independence through an integrated network of resources to meet their physical and emotional needs.
Case managers collaborate with seniors to plot a course that enables them to remain in their homes, performing safety, nutrition, medical and financial assessments to prioritize, address and prevent risk factors. Social workers also troubleshoot to find solutions to Medicare problems, provide referrals to assisted-living facilities, monitor prescription use and deliver monthly bags of healthful groceries to low-income seniors.
An integrated approach can help streamline medical red tape, fill in gaps in coverage and encourage seniors to prioritize their needs, said Megan Wadkins, program director of senior services.
“We want to find out where they are and what they need to remain in their homes safely, successfully and with dignity,” Wadkins said.
The program’s in-home safety assessments are particularly valuable in preventing falls. CSA interns from the University of San Francisco developed a Fall Risk Assessment Tool to measure the risk of falls, and will connect seniors to home care or recommend a Lifeline Medical Alert service, if neccessary, Wadkins said.
“We try to get things in place that help mitigate their fears and give them strategies,” said Maureen Wadiak, CSA associate director. “We work with them based on their individual needs and desires.”
According to Wadiak, the program specifically targets seniors with chronic health problems. After discharge, 18 percent of senior patients nationwide are readmitted to the hospital. CSA social workers and nurses visit seniors in their homes to educate them on managing their medications and to encourage them to follow doctors’ orders. Thanks to their intensive efforts in providing hospital-to-home care, only 5 percent of CSA’s seniors wind up back in the hospital, she said.
“We follow best practices, using intensive case management and coordinating with the hospital upon discharge to achieve the optimal outcome,” she said.
This year the agency has managed 251 cases – a combination of one-time home visits and ongoing, comprehensive follow-up care. Some seniors engage the agency themselves, others are referred by family members, neighbors, El Camino Hospital, the Los Altos and Mountain View senior centers, the Day Worker Center of Mountain View or Avenidas.
CSA endorses an “empowerment-based model,” Wadkins said.
“We believe in self-determination,” she said. “We want them to make decisions and determine their course of care.”
Wadiak said the number of seniors availing them of themselves of CSA’s services has nearly doubled in the past year, due largely to the agency’s outreach efforts through the local faith community and the downturn in the economy.
“Seniors’ incomes are fixed, but the cost of living still goes up,” she said.
In Santa Clara County, the largest number of people 60 and over live between Sunnyvale and Palo Alto, Wadiak said, and local communities are incorporating adaptive design factors that cater to the senior demographic, including aesthetically pleasing public elements for those in wheelchairs or suffering from arthritis.
CSA’s case-management services are free, though donations are accepted.
CSA needs volunteers to help with its senior services, including in-home social visits, escorted transportation to doctors’ appointments and grocery shopping and other errands. The agency provides an orientation and training on aspects of healthy aging. Volunteers must be 21 or older, and retirees are especially welcome.
“In this fast-paced environment, people really need to slow down and listen,” Wadiak said of the benefits of volunteering. “If they do, the wisdom they’ll receive is amazing – these seniors have lived incredible lives.”
To volunteer, call Alison Hopkins at 964-4630.
For more information on the Case Management Program, visit www.csacares.org.