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State Level Care Coordination

New York State

SWLI is partnering with the New York State Department of Health and the State Office on Aging to develop a successful blueprint for improving older adult care in New York State.

As part of this process, we are analyzing care models nationwide and engaging social workers, nurses, doctors, and other service providers and consumers in roundtable discussions to build consensus for standards for comprehensive care coordination and a qualified workforce to deliver that care. This model process is already being replicated by other states nationwide.

Policy Reports:

• Toward the Development of Care Coordination Standards: An Analysis of Care Coordination in Programs For Older Adults [PDF]
  
• Who is Qualified to Coordinate Care? Recommendations presented to the New York State Department of Health and the New York State Office for the Aging [PDF]

California State Loan Forgiveness for Geriatric Professionals

CAP worked with the California Social Work Education Consortium (CalSWEC) to provide research, technical assistance and coalition building around loan forgiveness for geriatric professionals. This work resulted in Senator Patty Berg's introduction of AB 2543 (The Geriatric and Gerontology Workforce Expansion Act) to the state legislature, where it passed and was subsequently vetoed by the governor.

This effort provides a model for SWLI to work with aging-focused and educational organizations in other states to launch similar initiatives.

CAP in Illinois

CAP also has worked with Illinois, at first with a statewide consortium of social workers in the field of aging and then more specifically with Rush University. Collaboration with Older Adult Services of Rush University was undertaken to design and implement an evaluation of its pilot hospital discharge program, in which a social worker makes post-discharge follow-up calls to at-risk elderly patients, their family members, and/or referral agencies to ensure that recommended services are provided on a timely basis.

Rush Older Adult Programs’ Enhanced Discharge Planning Program (EDPP) provides telephonic short-term post-discharge social work services that assess and intervene from a biopsychosocial perspective for at-risk older adults returning home after an inpatient hospitalization. EDPP follows a four-step process to with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge:

1. Ensure patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs
2. Connect patients to outpatient health services (ex: home health, in-home services, dialysis, radiology, laboratory services, specialty care) with particular emphasis on the first physician follow-up appointment
3. Supporting caregivers to reduce stress and burden

This model would not be possible without the Hartford Partnership Program for Aging Education, which trains professionals in the complexities of geriatric social work.