The challenge. Some 18 percent of the 770,000 people living in San Francisco are age 65 or older, a figure expected to rise rapidly as the baby boomer population ages. One-third of the city's elderly population has incomes at or below $14,453, and a majority is non-white.
Although San Francisco has many services to support older adults, a community survey in 2000 found that many elders knew little about them. The network of services for aging adults was fragmented and uncoordinated, and city and county agencies and nonprofit community organizations often operated in "silos," rarely collaborating.
Beginning in 2002, a community partnership directed by the city's Department of Aging and Adult Services launched an effort to improve coordination of long-term care and community-based aging services for the most vulnerable older adults. The initiative was funded by Robert Wood Johnson Foundation (RWJF) through its Community Partnerships for Older Adults national program.
The project. The first step was to develop a wide-ranging strategic plan. The 30-member Living With Dignity Policy Committee (an unofficial advisory body for the Department of Aging and Adult Services) provided overall guidance. A Strategic Plan Steering Committee that included service providers and consumer advocates, as well as a staff workgroup, were created to participate in an intensive 18-month-long planning process.
A total of 21 separate stakeholder meetings were held to develop strategies and objectives on topics including long-term care services and supports; racial, ethnic and cultural community needs; discharge planning and community placement; housing and homelessness; Medicaid waivers; overall system issues; policy and planning issues; and resource development issues.
The resulting strategic plan "was a milestone for San Francisco," said Bill Haskell, the partnership's project director. "It was the first time there was a document you could point to and say, 'This is what we want to do. This is what this movement is all about.'"
Four goals. The plan zeroed in on four priorities:
- Strengthen and sustain community partnerships responsive to under-served populations
- Enable better transitions between home, community-based and institutional services
- Improve communications strategies so that the public and providers know what long-term care and supportive services are available
- Encourage greater collaboration among community-based service providers, consumers and other organizations
Gaining clout in city hall. Since the strategic plan was tilling new soil for the city, the Living With Dignity Policy Committee and the Department of Aging and Adult Services sought high-level buy-in to insure its implementation. In 2004, then Mayor Gavin Newson appointed a 38-member Long-Term-Care Coordinating Council to oversee implementation of the plan and to be an official body providing policy guidance to the mayor's office.
The council, which had—and continues to have—direct access to the mayor's office, comprises some members of the original Living With Dignity Policy Committee, along with Haskell and other core leaders. It also includes representatives of the older adults and adults with disabilities being served, Haskell said. "We have older adults and people in wheelchairs, people who are deaf, blind and developmentally disabled who come to the meetings. When the people around the table are using every possible service and resource, that keeps you current."
In 2005, the Department of Aging and Adult Services gained a new executive director, Anne Hinton, who has long experience in administering government aging services programs. Hinton immediately saw the importance of a community-based process of improving the long-term-care system and worked closely with the council.
Bringing the table to the community. Just as aging services were isolated from one another, so too were the many community-based organizations serving minority and underserved groups in San Francisco. To encourage collaboration, the strategic plan recommended setting up four mini-partnerships in the African American, Latino, Asian Pacific Islander, and lesbian, gay, bisexual or transgender (LGBT) communities.
Getting these partnerships up and running was rocky. At the first meeting of the African American partnership, nobody showed. "We found out that many of them did not feel safe meeting in a government office," Haskell said, "so the next time we held the meeting in a local church and people came."
It was a lesson that the project applied to its relationships with all of the mini-partnerships. "We learned to bring the table to the community," Hinton said. "We had to build trust…and to do that we needed to be willing to meet in the most appropriate venue in their respective communities. This included neighborhood senior centers, churches, public housing buildings and community-based adult day health facilities."
Going with the ebb and flow. The city provided trained facilitators to run the meetings of the mini-partnerships, freeing participants from extra administrative tasks and keeping the work on track.
Participants learned to accept a certain ebb and flow in the membership, strengths and vitality of their partnerships over time. "The engagement level of these partnerships comes and goes depending on their voluntary participation," Hinton said. "However, if these groups are nurtured in ways that allow for the ebb and flow, they take root."
The four mini-partnerships did take root and made some significant accomplishments:
- When older adults in the LGBT community partnership expressed fears that they might have to return to the closet to receive long-term-care services, sensitivity training was provided for non-LGBT-specific service providers. The LGBT group also collaborated with mainstream organizations, including the Alzheimer's Association and the American Cancer Society, to promote more sensitivity in service delivery.
- The African American community partnership conducted an advocacy campaign that resulted in improved sanitary conditions and food quality at FoodsCo, the only market in the predominantly African American Bayview-Hunters Point neighborhood.
- The Latino community partnership created "Latinos Visibles," a support group and networking coalition for Latino caseworkers, published a resource directory of Spanish-speaking providers and advocated successfully for more Spanish-speaking social workers. Their efforts were featured on the Spanish language news.
- The Asian Pacific Islander community partnership published a community resource guide that included a detailed list of agencies serving its communities and the languages that each service provider spoke.
The Department of Aging and Adult Services continues to staff the four mini-partnerships. "The four community partnerships are recognized as a voice that was not previously available," Hinton said, "and they are seen as resources to access these historically underserved communities."
Bringing services to seniors in public housing. In its early planning, the overarching body, called the San Francisco Partnership for Community-Based Care & Support, had discovered a particularly glaring gap in a city known for having a wealth of services for elders. Some 2,300 older adults lived in 23 public housing buildings, yet there was not a single social worker to serve them.
The Services Connection pilot project, a collaboration between the Department of Aging and Adult Services, the San Francisco Housing Authority, and other community partners, was formed to address the problem. When service teams went into the buildings they discovered that many of the residents were unaware of services right in their own neighborhood. Project staff led a number of tours, either by foot or in a van, pointing out to residents the senior centers, health clinics and meals programs—often within a few blocks of where they lived.
The project also invited service providers into the buildings, and in fairly short order, residents had access to transportation, home care, medical care, meals and exercise programs.
It was a lesson in trust building, Haskell said. Both the residents and the housing authority were at first leery of project team members entering their buildings and asking a lot of questions. But the cool reception eventually warmed.
As a result, an elderly non-English speaking Chinese woman got comfortable enough with the team to mention her aching teeth and was referred to a dentist. The team also convinced the Lorraine Hansberry Theatre to donate 24 tickets for two performances of a play, giving isolated residents an unexpected outing.
Services Connection now operates in 16 of San Francisco's 23 public housing buildings. The city provides much of the funding, supplemented by a $375,000 grant from the U.S. Department of Housing and Urban Development's Resident Opportunities for Self-Sufficiency (ROSS) Program. A total of 1,670 San Francisco Housing Authority senior residents are being served.
Influencing public policy. In 2007, in part because of advocacy by the Long Term Care Coordinating Council, the mayor and the Board of Supervisors created a $3 million annual Community Living Fund. The fund can be tapped to provide supports to maintain people in their homes—such as case management, money management, community-based services and home modifications. The allocation remains part of the city's annual budget.
Another of the council's policy memos to the mayor's office resulted in a $100,000 allocation to develop a strategy for excellence in dementia care. The approach, which includes a training and education program and recommendations for implementation, was the first municipal strategy in the United States and received a $20,000 award for innovation from the Rosaline and Arthur Gilbert Foundation.
More work to do. Between March and October 2008, the council involved some 300 people in the community in creating a new four-year strategic plan (2009–2013). The new vision goes beyond providing the services people need, to considering a broader, more fundamental concept: what people require for "a good life." This new strategic plan includes numerous recommendations now being implemented to make improvements in the network of home and community-based long-term care and supportive services for older adults and adults of all ages with disabilities.
"Remember that Helen Hayes documentary 'No Place Like Home'?" Haskell asked. "She interviewed people in trailer parks, in middle-income tract homes in Long Island, in fancy mansions and where did they all want to live when they were old? Not in a nursing home. They want to live at home, whatever home means to them."'
Living at home with vitality remains the goal in San Francisco. In April 2012, the organization is sponsoring a meeting for LGBT and disabled elders. More information is available on their website.
RWJF perspective. Community Partnerships for Older Adults was an eight-year, $28 million national initiative of the Robert Wood Johnson Foundation (RWJF) that supported 16 communities to create collaborative partnerships to address the many gaps and inefficiencies in long-term care and supportive systems for vulnerable older adults.
RWJF Director of the Vulnerable Populations Team and Senior Program Officer Jane Isaacs Lowe notes, "One of the goals was to make what is a patchwork of long-term-care services in communities behave more like a coordinated system. We wanted to make sure that along that continuum of care, elders in communities had the breadth of services they needed.
"In general, the partnerships have demonstrated that innovations are possible in communities across the country—that allow people to age in place and that make for better care delivery for people with long-term-care needs."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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