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Efforts to Outcomes: National Church Residences’ Care Guide

In your experience, what are some good examples of health and housing working together in ways that have promoted positive outcomes for seniors? What has made these programs successful? View the full forum.

By Erika Poethig and Pamela Blumenthal

Among the many partnerships and innovations between housing and health providers to help seniors age well, National Church Residences’ efforts to identify and support those residents most at risk through its Care Guide assessment tool is a promising practice. Housing providers can play an important role both as a platform for improved care delivery and by coordinating care as the “eyes and ears” on the ground where residents live.

National Church Residences’ Care Guide enables service coordinators to play an active role, rather than being reactive as emergencies arise. They use the assessment tools to identify current issues for individual residents as well as anticipate difficulties. They can then put together a service plan, conduct needs identification and work with the resident on care management, helping seniors overcome barriers to aging well.

National Church Residences uses Care Guide as an integral part of a four step process:

  • Assess residents so the service coordinators know the residents better and can help them overcome barriers to aging well.
  • Stratify residents as to need and vulnerability to best target resources.
  • Support residents in self-management of chronic medical conditions.
  • Structure social networks within housing to create a culture of thriving and vitality.

Care Guide incorporates several screening tools. It includes the Rand Vulnerable Elderly Survey. The VES score, between 0 and 10, identifies seniors at risk for health deterioration. National Church Residences’ service coordinators identify those who have scores of 8 or above (the “high risk” group), and work to ensure they are able to access the services they need. They then focus on the “rising risks” to keep these seniors stable. The staff works to encourage and enhance individuals’ ability to participate in their own care. The National Church Residences’ team is piloting use of the Patient Activation Measure to help with this step.

Two components of National Church Residences’ program deserve emphasis. First, at its core, Care Guide is about building relationships. This takes time and commitment on the part of the staff, yet it yields significant benefits. Only after establishing a trusting relationship will residents engage and take the assessment or work with the service coordinator on a care plan.

Second, staff recognizes the need to have the individual invested in changing his or her health. This can be particularly challenging when working with people who feel they have little control over their lives. It can be hard to convince them they do have control, which is a necessary first step in having them engage in their care process. Service coordinators use motivational interviewing, a technique to reduce ambivalence to change. The goal is to have residents become more engaged and active in producing positive results for themselves.

With Care Guide, National Church Residences can target interventions. For example, once the service coordinator determines residents’ needs at a property, the organization can partner with the appropriate service providers to meet those needs.

While National Church Residences uses Care Guide to evaluate the effectiveness of its service coordination, no formal evaluation has been conducted of the benefits of Care Guide. The field would benefit from an evaluation of the components of Care Guide to learn how strong relationships, proactive service coordination, and greater engagement in self-care relate to healthy aging for seniors.

Erik Poethig is the director of urban policy initiatives at the Urban Institute. Pamela Blumenthal is a senior research associate at the Urban Institute.

Welcome to the BPC Health and Housing Expert Forum. Each month contributors from different parts of the health and housing sectors will be invited to respond to a discussion topic. Have a question you’d like us to consider? Please leave it in the comments.

Any views expressed on this forum do not necessarily represent the views of the Health and Housing Task Force, its co-chairs, or the Bipartisan Policy Center.

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