Community Life for Seniors Project

Topics	Aging Health promotion and disease prevention Networking and collaboration
States served	New Hampshire
Description	Through a consortium of health service providers spearheaded by Home Healthcare, Hospice & Community Services (HCS), the Community Life for Seniors project established a point of contact for the elderly population to access all needed health and social services available in the community with the specific goal of enabling elderly individuals to remain in as close to normal living circumstances for as long as appropriate and desirable. The project's early intervention program was designed for elders who are not receiving long-term care services but who are at increased risk of becoming injured or isolated within the county. Achieving the goal of the early intervention program involved: (1) identifying elders who were truly at risk of needing community and long-term care facilities; (2) screening those elders for risks and the interventions that were within the project's scope to provide; (3) providing followup assessment to ensure that screened seniors received the recommended services; and (4) providing ongoing care coordination to monitor the individual's needs and to ensure that the appropriate services were received.
Services offered	Specific services provided through the project included a 12-week exercise, strength training, and balance program with 90 enrollees; educational sessions on topics such as kitchen health, fall prevention, medication safety, safe winter walking, and exercise; referrals for chore services and minor home repairs; personal case management by an assigned team member who ensured client
Results	The concept of locating and identifying elders before they get into the healthcare system due to illness or accident was innovative. A single point of contact for isolated elders that involved three to five area agencies working together on individual clients is also innovative in itself.
Replication	There are two challenges to using the Community Life for Seniors project model: (1) initially it is difficult to find the clients; (2) once the clients are numerous, the long-term problem is to find a way to continue to fund the services and maintain the regular contact needed to keep ahead of any developing health or safety issues for seniors that may lead to loss of independence. Starting with the less isolated seniors is an easier approach to finding clients. Once the community buys into the services being offered, a steady stream of leads and referrals will follow, bringing in the more isolated cases. Including a social worker in the daily operations is essential to program success, especially with more complex clients. Maintaining enough staff to keep up with the growing caseload is essential; however, developing a permanent funding source for that level of staffing is a challenge.
Source	Outreach Sourcebook, Vol. 9, 1999-2002, Office of Rural Health Policy
Contact person	Judith P. Harris, Director of Quality Management Home Healthcare, Hospice & Community Services, Inc. P.O. Box 564 69L Island Street Keene, NH 03421 Phone: (609) 352-2253 Fax: (603) 358-3904
Date added	July 11, 2005

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