South Shore Elder Services, Inc - Area Agency on Aging Area Plan FFY 2018-2021
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South Shore Elder Services, Inc. 1515 Washington Street, Braintree, MA 02184 Area Agency on Aging Area Plan FFY 2018-2021
Table of Contents
1. Map of Planning and Service Area Page 4
2. Executive Summary Pages 6-8
Context and Overview of Goals and Objectives
3. Area Plan Narrative Pages 10-26
4. Attachments (to support Area Plan Narrative) Pages 29-35
Attachment 1 – FFY 2018 Funded Programs
Attachment 2 – Summary of Needs Assessment
5. Appendix Pages 38-59
Attachment A: Area Plan on Aging Assurances and Affirmation
Attachment B: Area Plan on Aging Information Requirements
Attachment B-1: Grievance Policy
Attachment B-2- Disaster Preparedness
Attachment C: AAA Organizational Chart (to follow)
Attachment D: AAA Corporate Board of Directors- Form 1
Attachment E: AAA Advisory Council Members- Form 2
Attachment F: Focal Points Document – Form 3
Attachment G: AAA Funded Services Form 4a
Attachment H: AAA Title III – C, D, E and OMB Funded Services – Form 4b
Attachment I: AAA Title III E – Family Caregiver Breakout – Form 5
Attachment J: Projected Budget Plan – FFY 2018
Additional Attachments
a. Area Agency on Aging Data Profile 2016
Services and Supports – pg. 1
b. Attachment 4 – Outreach Services Packet
c. Attachment 5 – Annual Report
d. Attachment 6 - IOR Home Heating Assistance InformationMap of South Shore Elder Services, Inc.
Planning and Service AreaExecutive Summary South Shore Elder Services, Inc. Area Plan on Aging 2018-2021
Executive Summary South Shore Elder Services, Inc. (SSES) is a private, non-profit agency established in 1977. The agency serves nine towns (Braintree, Cohasset, Hingham, Holbrook, Hull, Milton, Norwell, Randolph, and Scituate), and two cities (Quincy and Weymouth). Although SSES is not considered rural according to the U.S. Census (an area which contains less than 100 persons per square mile), there are some communities within the (PSA) which are more “rural” than others (e.g. some communities can access resources easier than others such as community transportation). SSES provides a broad range of programs and services to people age 60 and over to promote elder independence and services to caregivers. SSES also provides information, resources, and support to caregivers who may be under the age of 60 years old and caring for someone 60 years of age or older. A Board of Directors representing our communities governs the agency through planning, policy development, and oversight of the programs and services it delivers. An Advisory Council advises the Area Agency on Aging according to the needs of elders and caregivers in the PSA. South Shore Elder Services (SSES) has much to be proud of for its commitment to successful aging. Its forward thinking is exemplified by the long-term case-management needs of older adults to enable them to remain living where they desire (own home or apartment). We have an extensive network of engaged volunteers to provide money management, friendly visitors and, above all, home delivered meals to elders in our Planning and Service Area (PSA). SSES conducts a Needs Assessment study every four years to identify the areas of greatest local need in preparation for the development of an Area Plan. This Area Plan summarizes SSES’s strategy to address needs identified nationally by the Administration on Community Living (ACL): strengthen and expand core programs, participant-directed/person-centered planning, and elder justice. In addition, the Area Plan addresses locally identified needs of housing, transportation, health care, mental health care, maintaining independence, and nutrition. The developed strategy will direct SSES for the next four years throughout the PSA and will expand and evolve as needed. As strategic planners, SSES and contracted agencies use a variety of data to enable optimal decision-making. Weighted funding-formulas, census Massachusetts GIS (Geographic Information System) are used to help target resources for those most in need. Integrated approaches to service delivery by SSES staff and community partners effectively leverage public, private, and non-profit resources to meet the changing and rapidly-growing needs of older adults. Innovative alternative programs are used to engage public-private ventures such as revitalizing the senior nutrition sites by introducing a lighter second choice meal which hopefully will engage the younger seniors. Success is not without challenges. The significant growth of the Haitian, Asian-Speaking and Vietnamese populations and other marginalized populations in our PSA is a challenge. The focus is to provide services that are consumer directed and culturally sensitive. Currently, efforts remain intentionally intensified to include enhancement of resources directed to meet such needs and will continue as SSES funds Title III Supportive Services, Nutrition Services, Disease Prevention/Health Promotion and Caregiver Programs in the upcoming FFY.
Since 1978, or for nearly 40 years, SSES has served as an Area Agency on Aging (AAA). In this
capacity, we act as a single point of entry for state-subsidized elder services for the 11
communities that make up our PSA. The state-subsidized programs include the Home Care
Program, the Enhanced Community Options Program, the Community Choices Programs and
Respite/Over Income. Services provided thorough these programs include but are not limited
to: homemaking, personal care and adult day health.
In this role, our mission and purpose is driven by the vision of Executive Office of Elder Affairs
(EOEA) and the Administration for Community Living (ACL) to work closely with local
Councils on Aging and other agencies and organizations to develop a comprehensive,
coordinated and cost-effective system of home and community-based services that help seniors
maintain their health and independence in their homes and communities while having the
supports necessary to maintain their wellbeing and dignity. As an AAA, SSES works to increase
awareness among other agencies, group and the public about the needs of older people, educate
caregivers, and inform the public about our services. We make special efforts to reach and
prioritize the delivery of services to the following population:
Elders who are Isolated and/or Live Alone
Low Income Elders
Minority Elders
Veterans
Socially Isolated Populations (including limited English-proficient elders and
lesbians, gay, bisexual and transgender elders)
We do this by advocating for seniors, young and disabled, caregivers. This could include
directly providing services such as Money Management, Nutrition and In-home services,
ensuring that other critical services such as transportation and legal advice are available through
contract with and grants to other agencies.
In addition to the Title III, SSES also works as a partner with various organizations in seeking to
address the focus areas established by the ACL. Specifically, SSES seeks to address the needs of
target elders in relation to Older Americans Act (OAA) core programs: ACL discretionary
grants, participant-directed/person-centered planning, and elder justice. We do so by requiring
responding agencies to specify their plans for providing identified services to target group elders
in the region. This Area Plan provides a detailed explanation of our efforts to address the
established focus areas; either directly with Title III funded programs and services, and/or
indirectly with administrative support to other agencies and programs working on these areas.
See the attached list of FFY18 SSES Title III sub-grantees.
Through working with other community organizations, SSES not only receives referrals for
services, but SSES also provides information on the variety of community organizations as
service options for elders and caregivers in the Planning and Service Area (PSA). SSES has
partnered to develop specialized services for elders and caregivers which include support groups,
a strong relationship with the Alzheimer’s Association, Southern Mass Aging and Disability
Resource Center (ADRC) and Greater Boston ADRC. Our newest community partner, the
Prevention and Wellness Trust Fund (PWTF) focuses on older adult Falls Prevention.Context:
Part of our responsibility as a AAA is to maintain a comprehensive understanding of the
greatest unmet or under-met needs of elders who reside in the region. Our most recent Needs
Assessment project took place between September and December 2016. This was accomplished
through various means, including surveys of provider agencies, data collection and focus groups
held within the community we serve consisting of adults and caregivers. The major issues that
cut across our focus groups were:
Transportation– for non- medical such as ability to worship, visit spouse or partner in
hospital or nursing facility, travel in evening to support group; little availability in some
areas, accessibility issues in others.
Housing – long wait lists, cost of non-subsidized housing, lack of American with
Disabilities Act (ADA) compliance in older units, home repairs, acceptance issues (for
LGBT elders, to a lesser extent ethnic minorities)
Information on available services– this was related to communication barriers (deaf &
linguistic minority), complicated health insurance, insufficient outreach and mental
health services both in the community and at home.
Financial– prices for food, housing, heating oil, etc. are rising faster than elders’ incomes
to meet their needs. Many elders had low incomes during working years and have low
Social Security checks and now find they do need assistance with managing money
Communication barriers –were related to deaf or linguistic minority status, but also
include cross-cultural misunderstandings. Such barriers complicate access to all other
services and increase social isolation. This also included sensitivity to Veterans and
LGBT needs.
Goals and Objectives:
All focus groups were open to the public and anyone who had a vested interest in the topic was
welcome to attend. The overall goals of SSES for 2018-2021 for each of these themes include:
● Transportation: To increase access to transportation for necessary services such as rides
to medical appointments, rides to social activities, and rides for shopping.
● Housing: Strengthen housing with supports options
● Financial Concerns: To maintain and expand the Money Management program to help
resolve and prevent financial exploitation of vulnerable elders.
● Mental Health: To increase support and services to elders and caregivers in the SSES
PSA who have mental health concerns or have a loved one with mental health concerns.
● Minority Elder & Socially Isolated Populations: To increase access to information,
resources, and support to culturally sensitive and appropriate servicesArea Plan on Aging 2018-2021 Narrative
Administration on Aging Focus Area Plan
Focus Areas for the 2018-2021 Area Plan on Aging and SSES Goals and
Strategies in support of those areas.
Focus Area #1: - Strengthen and Expand Older Americans Act Core Programs: Using the
2017 Needs Assessment Project as a basis in support of programs and services, SSES will
continue to strengthen and expand Title III and VII services and integrate these core programs
across the our elder network.
The majority of South Shore Elder Services programs are provided under a contract with the
Massachusetts’ Executive Office of Elder Affairs (EOEA), as an Aging Services Access Point
(ASAP), to provide services to frail, low income elders in 11 cities and towns in Plymouth and
Norfolk counties, who meet financial and clinical eligibility. Other funding is provided through a
contract with EOEA that designates South Shore Elder Services as an Area Agency on Aging
(AAA).
South Shore Elder Services (SSES) does not have any known Native Americans in the planning
and service area (PSA), and therefore cannot address this focus area. While we have had a few
individuals identify themselves as such, we do not work with any tribal council.
SSES continues to prioritize protecting elders and their rights. The results of our most recent
focus groups establish that the supportive services provided by SSES are identified as a primary
emphasis needed to meet the needs of elders and their caregivers to promote their independence
and wellbeing. SSES will continue to address this in a variety of ways including programs
offered at SSES as well as partnering with community organizations.
Intake, Outreach, and Referral Department is responsible for the information and referral
components of the agency. There are five IOR staff, four are Certified Information & Referral
Specialists for both Aging and Disability (CIRS A/D). Our Specialists respond to all requests
for information, services and benefits. The IOR Department provides assistance with
applications, so that elders, adults with disabilities and their caregivers can make informed
decisions about care options and receive supports for which they are eligible. The IOR staff
provides a “no wrong door” experience for consumers seeking information about services and
benefits for adults with disabilities, older adults and their caregivers.
The IOR Department provides a single entry point to apply for public benefits and services via
trained staff. Our Specialists are available to complete referrals to connect isolated and low-
income elders and adults with disabilities apply for public benefits, such as SNAP (Supplemental
Nutrition Assistance Program, also known as food stamps), Medicaid and SHINE to help them
understand their health insurance options.The IOR Department is responsible for handling all of the intakes for Home Care, Family Caregiver Support Program, Home Delivered Meals and Money Management. . The staff work closely with databases, including 800AGEINFO, e-discharges and paper resources to be able to respond to inquiries regarding local, statewide and national resource and service information. This information includes outreach and education events targeted to family caregivers, including evidence based workshops, support groups, public forums and health education programs. In addition one of the IOR Specialists provides Enhanced IOR Services and will conduct home visits for emergency services as necessary. Due to the increasing aging population, SSES will continue to provide this important function to the consumers in our region. Annually, the SSES Information Outreach and Referral Department Manager develops informational flyers and booklets on a variety of topics (such as a guide to fuel assistance, weatherization and conservation resources, preparing for a winter weather emergency, and a hurricane disaster supply kit checklist) and distributes the information to community members as well as to Councils on Aging. (See Attachment #6) In addition to IOR phone assistance, SSES has also recognized the importance of disseminating written information into the community. SSES continues to maintain a resource library with community information available for anyone to take home with them. It is through all of these collaborations that agencies help maximize the resources available to elders and caregivers. Efforts will continue to expand the number of community collaborations over the next four years. SSES Nutrition Department provides daily nutritious meals and continues to look at ways in which the menu for home delivered meals and congregate meals can incorporate healthy foods and health education opportunities. We have added a second option choice at our congregate sites for a choice of a lighter meal or a meal from our menu. Our Nutritionist and Nutrition Program Manager along with the Caterer (Lindley Food Service) are looking at creative ways to continue this over the next four years. Also, SSES is still looking at increasing our congregate sites. In addition to serving regular, diabetic, Asian, kosher and renal meals, our program includes Cardiac HDM for consumers in need of this specific meal plan. Recognizing that many of our communities have a strong Asian–speaking population, we are currently planning for another expansion of the Nutrition Program to include home delivered meals that are Asian ethnic meals. In addition to the Nutrition Program being a strong component of Title III Core Services, the continued expansion and variety of offerings is also responsive to Focus Area #2 by providing both caregivers and consumers a degree of choice and control that promotes independence and is culturally sensitive. Our Nutritionist will be conducting nutritional educational programs in the community on such topics as Sodium and Bone Health. SSES has also partnered with South Shore Visiting Nurses Association (SSVNA) and Greater Boston Chinese Golden Age Center (GBCGAC) to conduct the Healthy Eating Initiative. This initiative includes partnering with three Councils on Aging in the PSA who conduct the community education programs. SSES has also provided Title IIIB and Title IIID funding to community organizations to promote weight loss support programs, diabetes support groups, chronic disease self management programs, and healthy eating programs. This will continue over the next four years.
Our Volunteers continue to be the primary kitchen helpers and deliverers for the Meals on
Wheels program. Each meal site has its own roster of volunteers, mostly seniors, who work
Monday-Friday and the Volunteer Coordinator keeps a current database of all volunteers. SSES
has partnered with 10 different Special Education/Work programs to establish Meals on Wheels
delivery teams. Examples include The Higashi School, The May Institute, St. Colletta’s,
WORK, Inc., and Road to Responsibility. These continue to be very successful working
relationships and volunteer recruitment for this program will continue to remain a priority.
The Family Caregiver Support Program (FCSP) provides support, education, counseling and
resources for caregivers. This includes adult family members or other informal caregivers age
18 and older providing care to individuals age 60 and over; individuals who care for a person of
any age with Alzheimer’s disease or a related disorder; grandparents and other relatives 55 years
of age and older who are raising a child/children under the age of 18; individuals who are 55 and
over who are caring for an adult, age 18-59, with disabilities. Services provided by the FCSP
include telephone consultation, in-home assessments, long term planning, and links to
community resources. During the recent needs assessment process there were three caregiver
focus groups. The participants in these groups listed the top areas of concern as:
The need for more respite services
The need for more education to assist with planning
Social/emotional support (including mental health services)
Flexible supportive services to meet the caregiver’s needs
The Family Caregiver Support Program at South Shore Elder Services continues to work
diligently at improving outreach within the community and expanding programs to meet these
needs. Significant progress in educating our community has been made through attendance at
health fairs, presentations at local businesses, and internal trainings in the office, the SSES Board
of Directors and the AAA Consumer Advisory Board.
The Caregiver Specialist co-leads two Caregiver Support Groups that meet in the South Shore on
a monthly basis. In addition, the Asian Outreach Worker, at SSES, has developed a successful
program at the Braintree Department of Elder Affairs. The program is geared toward the Asian
population (which has nearly doubled, in Braintree, since the year 2000) and meets weekly.
These weekly meetings consist of social and cultural activities, guest speakers, open discussions,
and the provision of helpful information on various popular topics-including the stressors and
challenges of caring for an elder. Additionally, the Asian Outreach Worker, regularly meets with
Asian speaking elders and their caregivers in the larger community and will provide families
with information, resources, and support as needed.
The Caregiver Specialist continues to provide the beneficial service of Caregiver Counseling,
and has become more involved with the Massachusetts Commission on the Status of
Grandparents Raising Grandchildren- in hopes of reaching more members of this growing
population of caregivers. The Caregiver Specialist also continues its involvement with the
Alzheimer’s Partnership of the South Shore, and attends monthly meetings. We are very excited
for this upcoming FFY as our Caregiver Specialist has developed a blog that is included on ourwebsite. We look forward to adding this type of outreach to our caregivers that spend time on the computer. The Family Caregiver Support Program works to build a bridge through the support groups for those individuals who are balancing caregiving issues in order to create a community connection and a “safe” place to share their experiences. In addition to this type of support for the caregiver, the Specialist also will provide some education such as, “Ways to Communicate,” and “How to Improvise.” The FCSP will continue to strengthen its relationship with the Alzheimer’s Association, the Alzheimer’s Partnership of the South Shore, the VA, as well as the Massachusetts Commission on the Status of Grandparents Raising Grandchildren. This will be done by our increased presence and involvement at such notable events as the annual Walk to End Alzheimer’s and the Annual Educational Conference and Caregiver Day. SSES will continue to provide beneficial resources to caregivers by encouraging the use of online Support Groups and telephonic Support Groups, such as the VA Caregiver Support Line. Long Term Care Ombudsman Program covers 24 nursing facilities and rest homes. The SSES Ombudsman Program protects the rights of residents in Nursing Homes and Rest Homes. Our Volunteers are an essential component of this program. Certified Ombudsman Volunteers work with residents and their families to help ensure the highest quality of life for residents. Ombudsman Volunteers visit facilities regularly to advocate and advise residents of their rights regarding the quality of care. SSES hosts the required three day training at a minimum of one time each year and sends interested volunteers to local ASAPs to fulfil their training obligations. The Ombudsman Director and Assistant Director also plan to focus on Resident/Client Centered Care as part of their outreach this year as they discuss the overall Ombudsman Program. The Ombudsman Program Director conducts resident’s rights trainings with Nursing Home staff, SSES staff, and Nursing Home residents on a regular basis in order for them to be aware of the rights of residents in Nursing Homes. The Ombudsman Program also conducts trainings on abuse for Nursing Home staff. Additional community trainings are offered upon request and are tailored to meet the needs of the audience. A Long Term Care Ombudsman will meet with the residents of Nursing and Rest Homes on a regular basis in order to ensure that their rights are protected, and they will advocate on behalf of the residents as needed. The Ombudsman will also periodically consult with Greater Boston Legal Services (GBLS) on any legal issues that may arise. The GBLS Attorney meets with the Ombudsman staff annually to update staff on any new issues that may arise due to changes in regulations or laws. The Ombudsman staff also work collaboratively with the Department of Public Health during the investigation process when complaints of that nature occur. They also meet with the survey team annually when they visit a facility for inspection. The Ombudsmen also receive on-going trainings on a regular basis on such topics as the nursing home rating system, case resolution, guardianship, culture change, resident’s rights, etc. An Ombudsman undergoes extensive 3-day training before becoming a part of the program and visiting residents on Nursing and Rest Homes. (See Focus #3 for additional information)
The program also plans to collaborate on a community education program with the Family Caregiver Support Program to educate caregivers on nursing homes. Additional educational and learning opportunities were identified as a need by caregivers during the most recent focus group meetings. The Ombudsman Director and Assistant Director also plan to meet with the Council on Aging Directors and/or Outreach Workers as part of their future outreach to discuss the Ombudsman Program, and how it can help nursing home residents and their families. Money Management Program offers home based money management services to consumers having difficulty with budgeting, managing their checking accounts, paying routine bills and keeping track of financial matters. Trained Volunteer Money Managers assist consumers in managing their financial affairs through bill paying and budgeting. The population currently being served is predominately 60 yrs. and older (are sometimes socially isolated), an increased number of Protective Services clients, and a growing number of younger disabled consumers. (See Focus #3 for additional information). Additionally, these individuals demonstrate one or more of the following: cannot remember whether checks have been written, unable to maintain a checkbook register, have bills piling up and there is confusion of how to pay them. This list is by no mean conclusive. Overall, the Program will provide In-Home Support through monthly assistance with bill paying. It will provide financial security and independence, as clients are better able to meet their monthly financial obligations, establish and maintain a monthly budget, and keep better track of their finances. South Shore Elder Services (SSES) has been approved to provide Money Management Services as direct services through Title IIIB funds. This program and funding will begin Oct 1, 2017. The priority areas for funding based on the Needs Assessment which are part of our area plan include Services to Promote Safety and Security focusing on Financial. The MMP Coordinator works with other SSES staff to coordinate individual consumer care and will act as the Case Manager for consumers who do not receive Home Care services. The MMP Coordinator consults with Greater Boston Legal Services, or refers consumers to several elder law attorneys or elder care planners when needed. The Money Management Program utilizes a team of volunteer monitors, who audit client records on a quarterly basis. In addition to our volunteers, the program also has a volunteer Advisory Board, which meets 2x/ year. Our members represent banking, elder law and elder care planning, Councils on Aging, the Social Security Administration, law enforcement and volunteer bill payers. Transportation – Transportation, especially medical rides has been and continues to be identified as the top challenge faced in our communities. Over the next four years South Shore Elder Services will work with community partners to improve transportation services. Additionally, SSES will continue to coordinate, fund and provide high quality efficient transportation programs within the PSA. The SSES PSA is unique in that some of the communities in the PSA have more access to public transportation than others, which makes the lack of transportation compounded in some communities, for example a city such as Quincy has access to the “T” whereas many of the
towns in the PSA have very limited public transportation options. SSES has continued to provide Title IIIB funding to Councils on Aging for the MAP Program (Medical Access Program) which provides out of town medical transportation to individuals who are 60 years of age or older. Although the funding is limited, the Councils on Aging are able to access this resource when they can’t provide the needed transportation utilizing their own Council on Aging vans. This will continue over the next four years. SSES also contract with purchased service vendors to provide medical and adult day health transportation to priority populations especially frail, isolated, and/or low-income seniors who qualify for the various publically subsidized and contracted programs operated by SSES. Additionally, our region has begun and will continue to facilitate conversations regarding transportation challenges as well as work in collaboration with our Councils on Aging to discuss and promote community options, and participate in other opportunities to work to promote and improve transportation options. The transportation collaborative will also continue to identify ways to address transportation larger more regional needs that require cross town travel to hospitals, and doctors. The SSES Information, Outreach and Referral Department also provides transportation resources to anyone who calls looking for information regarding transportation services. Increase outreach and accessibility of services to LGBT – SSES will continue to raise sensitivity and awareness of the LGBT elder population by offering trainings, holding listening sessions, sponsoring events and supporting the work of the LGBT Aging Project. Trainings for internal staff have already taken place and outreach to the LGBT Monthly Luncheon will include a wider discussion of services and information available. Additionally, a panel discussion will be presented for staff on sensitivity and specific needs unique to this population. It is expected that these types of training will continue to grow moving forward. Outreach to Veterans – SSES has built a very robust Veterans Outreach Program which includes: meeting regularly with Joint Base Cape Cod and Hanscom AFB Retiree Affairs. These meeting include outreach in the clinical and medical arena, as well as with activities for Retirees and Veterans. We have a longstanding (2+ years) ad in the Otis Notice for Veterans Outreach. Within the last year we have incorporated an ad campaign which features services and recruitment efforts for workers to provide home care for Veterans. These ads have run in both the Otis Notice and SOCO/New England Monthly Magazine over the last 16 months and will continue over the next few years. We have had featured articles in the Otis Notice that have included one of our Board Members who highlighted in his very moving Keynote Address at our Annual Meeting; how his military service has shaped his adult life. We have had articles featuring other Board Members who were Veterans and our Outreach efforts for Veterans. We have a Veterans Board consisting of Staff, Board Members, Volunteers and family and friends who have served. We honor them in our office and have a traveling set of Boards that we have featured at our Legislative Breakfast, Volunteer Luncheon and at our Annual Meeting.
As part of our Legislative Outreach, we have met with legislators on the Joint Committee for Veterans Affairs, including the Chair, longtime members and our local representatives who serve on that Committee. We have provided an update of our Outreach to Veterans to our Legislators as part of our Legislative Breakfasts. We continue to support Veterans Outreach at events in the community, including ceremonies, Legislative events at the State House and in our catchment area, as well as events throughout Massachusetts. We have developed relationships with representatives of the Marine Corps Social Media team, with the Massachusetts offices of Disabled American Veterans, the American Legion, Veterans of Foreign Wars, the Marine Corps League and other advocates. We met with the former Department of Veterans Services for Massachusetts at an event at a local Council on Aging. We have had the Braintree Veterans Service Officer give a presentation to our staff. These activities have been ongoing and will continue to be a part of our plan going forward. The most significant addition to our outreach is that SSES is now the sole hub for the Veterans Directed Home and Community Based Services program in conjunction with the Veterans Administration. In this role, we have had extensive meetings with VA officials and the other ASAPs who are spokes in our hub. This program will likely continue to grow from the 11 ASAPs in the program. This entails close coordination with the VA Hospitals in Bedford, and those in Jamaica Plain and Brockton noted as VA Boston. Focus Area #2 Participant-Directed/Person-Centered Planning Some of the goals addressed in this section include Health Care System Coordination, a degree of choice and control over the long-term services and supports needed to live at home, services designed to access services and assist in overcoming language and cultural barriers, strengthen housing with supports options, and increase supports available to informal caregivers. Additionally, lack of the availability of affordable housing or “housing with supports” options was a common theme during the needs assessment period. In the same discussion, the need for assistance with home repairs and finding reliable vendors for property maintenance such a raking and snow removal was identified. Health care concerns for elders were an identified need during the most recent focus group meetings. SSES has three hospitals in the PSA, and SSES works closely with each of them. SSES is a member of two of the hospitals STAAR Initiatives Team and actively involved in reducing hospital readmissions. SSES is also actively involved in community partnership development with local accountable care organizations to streamline patient access to medical care and meeting the needs in the community. SSES also works closely with two of the Visiting Nurse Associations in the PSA (Norwell Visiting Nurse Association and Hospice, Inc. and South Shore Visiting Nurses Association). SSES has provided Title III funding to each of them in order for them to conduct evidence- based and community health education programs as well as provide support services to elders and caregivers in the PSA.
The IOR Department receives electronic discharges from South Shore Hospital (also known as e-discharges) for elders who will need home-based services upon discharge. This has proven to be a helpful transition for elders who need services in the home after a hospitalization. SSES will continue this effort as well as work to expand this streamlined method of communication with the other two hospitals in our catchment area over the next four years. Additionally, e - referrals are received from Manet Community Health Center for our Evidence-Based Falls Prevention and Home Delivered Meals programs. The SSES Home Care Program assesses the eligibility and the need of consumers for home and community based services. Reassessment and annual redeterminations ensure that service planning is meeting the identified consumer needs by the Care Managers and CAE Nursing Staff within the Home Care Program using an interdisciplinary model of care. Service plans are implemented coordinating the formal and informal components needed to address all identified needs. The Medicaid Team has an interdisciplinary approach to review all consumers enrolled in Home and Community Based Services Waiver to develop appropriate Plans of Care responding to individual needs in order to maintain consumers’ desire to remain in the community. This approach is essential as consumers on the Medicaid Team include those with more extensive needs. Housing - Affordable housing has become increasingly important during the difficult economic times of the State and the country and was identified as a high priority throughout each of the focus groups. This is supported by the increase number of referrals into the IOR Department. Our Housing Department and IOR staff receive a large number of telephone calls looking for and needing affordable housing on the South Shore. This continues to be a challenging area for multiple reasons which include: a lack of available housing on the South Shore and required qualifications to meet strict guidelines for housing opportunities. The SSES Housing Department and the SSES Information Outreach and Referral Department maintain a list of housing options on the South Shore area. SSES’ Housing Team work with local Housing Authorities to identify individuals that meet the criteria for the living arrangements as they are affordable, accessible, and provide an opportunity for increased socialization which helps isolation in the older population. SSES’s mission is to help individuals who are in their homes to remain in their homes (as long as they are safe), by providing some financial assistance (particularly related to home heating), along with locating additional resources to remain in the community. Current and future plans consist of SSES staff strengthening their relationships and collaborations with local Housing Authorities and other community agencies in the PSA. During the past several years, SSES has also provided funding to a local homeless shelter in Quincy (Father Bills & MainSpring) to provide daily nutritious meals to homeless elders on the South Shore. This collaboration has strengthened SSES’s working relationship with Father Bills & MainSpring. Together our agencies will explore opportunities for the future to work on decreasing the number of homeless elders in our PSA and develop creative solutions to address the need for additional affordable housing.
Our program goals over the next four years are to: To strengthen relationships with Housing Authorities on the South Shore, to acquire and build working relationships with private subsidized housing options, continued development of partnerships with community agencies, and to continue to acquire and strengthen housing resources. Asian Outreach - SSES has also identified the continued increase in the population of Asian elders and caregivers in the PSA. To help address the needs of this population, SSES has an Asian Outreach Worker who speaks Cantonese and understands the Chinese culture. He will continue to spend time with Asian elders and caregivers in the community to help connect them to resources, services and support in the community. The Asian Outreach Worker has advocated for the needs of these elders and caregivers in the SSES PSA and the Needs Assessment supports the following: lack of classes in the community that can teach Basic English, information, resources and support offered in the Chinese language, translation/interpretation needs, and assistance with medication management. Title III B as well as SHCP assist in offsetting these needs by providing resources to the Asian Community. Our ongoing partners include the local libraries such as the Thomas Crane Library where we host ongoing seminars, local hospitals and COAs to promote community centered activities for Asian residents, expanding new monthly gathering groups to include the Simon C & Fireman Community in Randolph where participants include Asian, Japanese, Vietnamese, Haitian, and Jewish seniors. The Senior Care Options Program (SCO) joins forces with Medicare and Medicaid to provide a comprehensive care plan to the meet the needs of low income seniors. In doing so, the SCO program does a thorough psychosocial assessment, which leads to the development of an integrated care plan. This allows for seniors to remain in the community. SSES currently holds a contract with Senior Whole Health, United Health, Tufts, NaviCare and CCA. SSES has developed strong relationships with each of the SCO Programs. It is imperative for effective service delivery that SSES works collaboratively with each program to meet the individual needs of the members. SSES has seen tremendous growth in the last four years that has required SSES to hire additional staff. In maintaining a collaborative relationship with of the SCO programs, SSES participates in quarterly clinical meetings with each SCO to ensure effective communication and service delivery. These meetings are focused on communication between the SCO and SSES. Specifically, the discussion will focus on the needs of specific members as well as programmatic issues. SSES is looking at contracting with at least one additional SCO provider. SHINE - With the many changes facing the pre-existing health care system and the rising cost of health care, it can be very confusing to find the appropriate health care coverage options. SSES is fortunate to have SHINE (Serving the Health Information Needs of Elders) volunteers thru our Manet Community Health Center partnership at the agency once a week who can meet with aging individuals, families and caregivers to present them with the best health care coverage options for them to choose based on their individual needs. In addition to the volunteer SHINE workers, SSES also has employees that have been trained as SHINE workers who are able to assist with navigating the intricacies of both the Mass Health application as well as the health care system.
The SHINE program is managed through the regional office located at HESSCO. The SHINE workers also help elders and caregivers understand state and federal benefits, as well as long- term care options. The IOR and Options Counseling Departments can also assist in providing information on local medical professionals and organizations that provide health related information/resources. These types of calls and the need for updated information remains steady and our services will continue to provide guidance to our communities over the next four years. Options Counseling is a free, short-term counseling service for elders, as well as young and disabled persons. Options Counseling provides consumers with information about long-term supports, as well as consumer directed decision support to help evaluate service options. This service is an interactive process whereby consumers, family members, and/or significant others are supported in their deliberations to determine long-term care choices in the context of the consumer’s needs, preferences, values, and individual circumstances. As part of the Massachusetts Aging and Disability Resource Consortium (ADRC), SSES plans to conduct more outreach for Options Counseling. Maintaining relationships within the community are crucial to the SSES and ADRC’s “no wrong door” policy. Options Counseling will establish an outreach plan, which identifies specific hospitals, rehabilitation facilities, nursing facilities, community agencies and other providers for outreach efforts to heighten awareness of Options Counseling services and generate referrals. Thus far, Options Counseling has been conducted, on a regular basis, at a local medical practice, as well as at a local elderly housing complex. Options Counseling will look to increase its service to the young and disabled population (ages 22-59). SSES will also strive to collaborate more closely with the ILC’s (Independent Living Centers.) ADRC - South Shore Elder Services has recognized the importance of working with organizations serving the disabled community and is a member of the Aging and Disabled Resource Consortium. The primary goal of the ADRC is to provide a “no wrong door” model to working with individuals and to make a streamlined transition for individuals from the disability network to the aging services and to provide appropriate resources to individuals. SSES is a member of one ADRC in. South Eastern/Southern Mass which includes collaboration with Independence Associates, Bristol Elder Services, Old Colony Elder Services, Coastline Elderly Services, and Southcoast Independent Living. Additionally, SSES works very closely with Greater Boston ADRC which includes collaboration with Boston Center for Independent Living. The service that the ADRC provides is Options Counseling, a shared program of each member of the ADRC to promote the ability of streamlined access to meet the specific self- identified needs of all individuals in the community. SSES continues to function as a member of the SEISM ADRC to collaboratively enhance partnerships, resources, and services to meet the needs of both elders and the young and disabled populations. SSES participated in consistent cross training with staff and members of the ADRC to enhance the knowledge of the aging disabled populations. LGBT – The concern for access to culturally sensitive services did arise during our most recent needs assessment. Presently, SSES’s supports a LGBT meal site located in a Unitarian
Universalist church in Braintree, a culturally isolated population. SSES will also be
implementing an ongoing panel to promote discussion on diversity, cultural awareness and
competencies and unique aging issues. The questions for the panel might include: “What are the
particular health issues for the LGBTQ community?” The goal for this upcoming year is to
create at a minimum an annual culturally sensitive and culturally appropriate training for staff
with additional resources provided throughout the year.
Mental Health Services-The areas of concern during the needs assessment process for mental
health included:
Loss and transitions in life were difficult as one ages.
Housing (lack of support for people with mental health needs, and lack of in-home
services for people with mental health needs).
Lack of treatment/resources and access to the services that are available can be difficult
The need to educate the public on mental health.
Issues of hoarding and recognition of this as a mental health issue which can also impede
remaining safely in the community.
SSES has taken the mental health needs of elders very seriously and has collaborated with
Mental Health Agencies, Council on Aging and Hoarding Specialists.
Since 2009, SSES developed a contractual relationship with South Bay Mental Health. With this
collaboration, SSES been able to deliver therapeutic services to consumers in their home and
the community. This agreement initially began by offering South Bay Mental Health Day
Program and home visits weekly. As the relationship with South Bay Mental Health has
unfolded, both parties have been working towards thinking creatively when working with
difficult consumers. As result, bridge visits and family case conferencing visits have been
developed. Bridge visits are utilized when a consumer is in a restricted environment such as a
nursing facility or hospital prior to discharge. The clinician will meet with the consumer to
discuss the consumer’s transition back to the community with service in place. Both parties
agree to maintain the highest standards of ethical conduct in this working partnership with one
another to offer quality services to consumers.
Discretionary Grants - Many times an elder’s rights can be protected through altering their
living situation or obtaining the paid assistance from another professional organization. Many
elders are low income and do not have the financial means in order to access these types of
supportive services. As an agency, SSES has also recognized the financial assistance needs of
elders (and caregivers) in the community. SSES has a Special Needs Fund that provides
financial assistance for a service or a product that can’t be paid for by other means. The Special
Needs Funds are available to anyone in the SSES PSA. SSES has made it a priority to provide
some financial assistance and to research other potential financial assistance programs for
individuals in need. In recent years, a large portion of funds has been utilized for the purchase of
heat/oil as several programs previously available for financial aid have lost their funding. SSES
will continue to look for creative ways to obtain additional funding for the Special Needs Fund
(e.g. through fund raising, private donations, and applying for grants) over the next four years.
(See Focus #3 for additional explanation.)The Volunteer Program at SSES is made up of multiple components that are integrated into our support services. The strength of our Meals on Wheels Program (MOW), our Friendly Visitor Program, as well as our MMP is due to the success and ongoing recruitment of volunteers. SSES Friendly Visitor volunteers are matched with isolated seniors who have little or no informal supports for social companionship. Consumers involved in this program are also receiving case management services through SSES. Volunteers make weekly visits for about 1 hour. Depending on the identified need, services include reading as well as taking the consumer out for a walk or drive even if the consumer is able to do so unassisted. Recruitment remains vital to the expansion and success of these services and currently the Volunteer Program is undergoing a restructuring due to the expanding MOW Program. There is a need for targeted outreach in specific communities to meet a growing need in this program. Outreach efforts are now expanded to include an increased use of social media, meeting with community businesses, corporations and civic organizations. All volunteers are CORI’d and trained by the Volunteer Program Manager before being placed. Quarterly training on relevant topics is offered by SSES for all volunteers. In anticipation of a growing population of frailer elders, younger disabled and minority ethnic consumers, volunteer trainings are being updated in order to better prepare our volunteers to serve these populations. This initiative not only helps the current consumers at SSES but also offers a socialization opportunity for active elders and caregivers in the SSES PSA. Connecting elders to employment and civic engagement remains a goal of SSES as part of healthy aging. The SSES Information, Outreach and Referral Department usually has a stipend staff person from Senior Service of America and and this collaborative has been very successful. SSES is committed to working with interns to help them effectively work with individuals as they age; SSES will also continue to offer internship placements at SSES over the next four years. SSES assists in funding the New England Homes for the Deaf, Inc. (NEHD) satellite location at the Senior Center in Quincy. All identified deaf seniors live in the South Shore service area and are able to receive services information/referral and weekly recreational opportunities through this led by a Program Coordinator who is also deaf. There are outreach activities to deaf and deaf- blind seniors, a “Community Bingo Night.” In addition, the Volunteer Center Coordinator provides transportation and interpretation for shopping trips and doctor visits on a weekly basis. The program has a positive impact on this unique population and NEHD will strive to maintain and improve the program with close partnership with other agencies and organizations. As the “Baby Boomers” age, SSES has noticed their increased interest in more recreational and social programs in the community as well as their focus on health issues. SSES has begun to see some of the Councils on Aging in the PSA begin to offer programs during the evening (for individuals to attend after work) and activities that appeal to a younger aging population such as yoga classes, journal writing, cooking programs, health education programs, etc. SSES supports the Councils on Aging in this effort and will provide information obtained from needs assessments to help the Councils on Aging develop future programming.
Caregiver and Respite Services: Respite Services include the provision of one or more Home Care Program services to temporarily relieve the caregiver of a consumer in emergencies or in planned circumstances. The purpose of these services is to relieve the caregiver of the daily stresses and demands of caring for a consumer and strengthen or support the consumer’s informal support system. In addition to services available under the Home Care Program, Respite Care services may include short-term placements in Adult Family Care, Nursing facilities, Rest Homes, or Hospitals. A caregiver is defined as person, regardless of place of residence, who is 18 years of age or older and provides assistance with Activities of Daily Living and/or Instrumental Activities of Daily Living, supervision, or social and emotional support as required by a Consumer on a daily basis without pay. SSES strives to meet the needs of the caregiver and makes it a priority to assess the stresses and issues during each visit or telephone conversation. The CM discusses if the services are meeting the needs of the caregiver and if not, they will consult with their supervisor to make necessary changes in the care plan. Case Managers also assist the caregiver in coordinating community services that may supplement the SHC Program services. Focus Area - Integration of Evidence-Based Programs into the OAA Programs: South Shore Elder Services is very active in promoting evidence-based disease prevention and the Falls Prevention programs as both an Area Agency on Aging (AAA) as well as an Agency Services Access Point (ASAP). In both of these roles, SSES continuously assesses for unmet needs as well as changing needs particularly in the area of Falls Prevention. Title IIID Matter of Balance (MOB) programs were funded in our communities this FFY. SSES is also excited to continue to fund the Matter of Balance Programs in our Councils on Aging and has a very strong MOB program for the Asian-speaking population. The Chronic Disease Management and Tai Chi are additional programs offered in our communities that promote Healthy Aging in our senior population. SSES FCSP staff has been trained on the Savvy Caregiver program. Overall, the wide range of evidence-based programs funded though Title III allows for a variety of programs to meet different needs. In addition to the Title III funding, SSES as an ASAP and AAA agency has taken a leadership role in making a difference to address Fall Prevention as part of the Prevention and Wellness Trust Fund (PWTF) targeting the communities of Quincy and Weymouth. The specific community interventions SSES have been providing are AHSA (Assisted Home Safety Assessments) and Matter of Balance classes. SSES has hired a Falls Prevention Coordinator whose primary role is to educate consumers, whether it is about falls prevention or other community programs/benefits they could be eligible for and/or benefit from. This pro-active approach has only enhanced our ability to be one of the top PWTF initiatives in the state but also provides a coordinated approach to introducing the role of the Falls Coordinator to individuals in Matter of Balance programs. SSES was the original pilot partner of the E-referral system with Manet Community Health Center. SSES has also advocated and pushed for widening the criteria of those that are able to receive AHSA. For our agency, it is about prevention, not those already in crisis. Our Fall Prevention Coordinator is also certified as a Matter of Balance coach. The focus in this
upcoming year includes a discussion about incorporating the MOB classes into other community dwellings that SSES has affiliation with, increased outreach internally as well as the Senior Center Health Fairs in our area. We look forward to working with our partners on evaluating these programs which support community living and enable our seniors to remain in their own home with a high quality of life. These programs are a benefit to our seniors and as they continue to make inroads into the communities, their outcome measures will describe the impact made and expected to make as we plan for the next four years. Focus Area #3 Elder Justice: SSES continues to prioritize protecting elders and their rights. The results of our most recent focus groups establish that the supportive services provided by SSES are identified as a primary emphasis needed to meet the needs of elders and their caregivers to promote their independence and wellbeing. SSES will continue to address this in a variety of ways including programs offered at SSES as well as partnering with community organizations. Protective Services Department - The SSES Protective Service Department is specially trained to assist elders and their families with sensitive situations that may contain physical abuse, emotional abuse, sexual abuse, financial exploitation, neglect or self-neglect. Each Protective Services Advocate takes a non-judgmental approach and looks to protect the well-being of the elder with the ultimate respect for his/her right to make decisions for him/herself. The goal of the Protective Service department is to make resources available to elders and their families which will allow the elder to remain safely in the community. Each Advocate works with the elder and his/her family to offer the least restrictive intervention possible with the purpose of having the least amount of disruption to the elder’s life. Some of the services offered may include: crisis intervention, safety planning, case management, home care services, referrals to appropriate resources such as counseling and support groups, alternative housing, family intervention, legal intervention, and advocacy. Protective Services are available 24 hours a day. Protective Service Staff is also available to consult on a situation where abuse or neglect is suspected. Within the past year, the Protective Service team continued with its achievements in providing information and outreach to the community to help raise awareness about elder abuse and reduce risk as well as taking the lead in Hoarding Task Force meetings which will continue in the upcoming year. This department has conducted community education programs on the topic of elder abuse, and has continued to train mandated reporters to help them identify the signs of elder abuse and neglect and the importance of reporting it. Outreach is also done on an annual basis with the local Police, Fire, COAs and Visiting Nurse Associations and contracted providers of SSES. Through a funding grant obtained by EOEA, a new financial assistance program has started, called “FAST” (Financial Abuse Specialist Team). This team has been established to assist Protective Service Advocates with complicated financial exploitation cases. The team includes volunteers within the community who have financial and legal expertise to help interpret complicated financial information. Our PS team is preparing to launch this program in
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