The challenge. In 2000, frail elders in Manchester, N.H., were not on anyone's radar screen. Many of these so-called "invisibles" were at risk—not because their houses lacked plumbing or utilities, but because the seniors themselves were no longer able to clear away heavy New Hampshire snows, replace a light bulb or do other basic household tasks.
Seniors Count, a community partnership led by Easter Seals of New Hampshire, spearheaded an initiative to address the many nonmedical factors that put older adults at risk. The Robert Wood Johnson Foundation (RWJF) provided funding through its Community Partnerships for Older Adults national program.
Background. In Manchester, an aging mill town of some 107,000 residents, the number of older adults is growing rapidly. By the year 2020, that population is expected to double, from 14,000 to more than 25,000—and the number of frail elders over 85 will grow even faster. Fifty-seven percent of inner-city residents live alone and many barely manage on Social Security payments that average less than $14,000 a year.
In October 2001, Easter Seals of New Hampshire brought together representatives from public and private social service organizations and local businesses in Manchester to consider how to help frail elders. They formed a task force, which became the Seniors Count Partnership—named to reflect the group's belief that "age does not diminish a person's worth and value to the community."
Some 200 people eventually joined, including older adults, caregivers, elected officials, representatives of public sector health and aging-related agencies, hospitals, local service organizations and businesses. Arlene Kershaw, director of Senior Services at Easter Seals New Hampshire, was tapped to direct the partnership.
Early data gathering highlights the problem. The partnership began its strategic planning with extensive data collection, a process that encouraged collaboration among institutions that had never worked with one another.
Their research identified severe service shortages, including lack of access to transportation, assisted living, and home care. City regulations threw up other barriers. At the time, zoning ordinances forbade homeowners from building "in-law apartments" so that frail elders could live close to their families. And social service agencies often would not allow their staff to drive clients to appointments, for fear they would be liable in the event of a fall or other mishap.
As frail elders required more services, coordinating them became more difficult. "If you are a 70-year-old who needs socialization but can still drive and get yourself to a senior center to have a congregate meal, that is one thing," Kershaw said, "but what if you have mental health issues, memory loss, mobility issues and you're poor?"
Making the "invisibles" visible. Seniors Count set out in 2004 to raise awareness of the problems facing frail seniors, to leverage services to eliminate gaps, increase choice and access, and supplement available financial and human resources.
At first, the plight of frail seniors was not obvious to the community or even to some of the people who were part of the partnership, Kershaw said. "There were business people at the table who said, 'What are you talking about? There are so many services for seniors. Why are they falling through the cracks?' So right out of the gate we knew we had to shine a spotlight on this invisible problem. We had to make it visible."
The partnership began with a public service campaign that focused on seniors suffering from dementia and memory loss. Using the tagline, "Remember, Seniors Count," the ads urged citizens to call their elderly relatives and to check in with elderly neighbors.
A second ad focused on the dangers of falling, the number one reason for unplanned hospitalization for seniors, with action steps people could take to help elderly relatives or neighbors avoid unnecessary falls at home. "We tried to plant an urgency about this," Kershaw said. "These elders were the leaders of your community, the people who made your community what it is. We should not, morally, neglect these frail people."
Catching the vision. To get residents thinking about how to make the city a friendly place to grow older, another ad campaign on radio and television and in print challenged the public to "Imagine a City," in which older adults had the supports they needed.
These campaigns established the partnership as the go-to source for issues related to aging:
The partnership's growing influence within government was a telling marker of its effectiveness. In 2010, a public health department planning survey for the first time designated frail seniors as a separate category. The city also designated Seniors Count as the aging resource expert for its Healthy Manchester Initiative. "One of our biggest successes," Kershaw said, "is that the mayor and the aldermen, most of the providers, the public health workers and the police all have frail seniors on their radar now."
Filling the "eldest daughter" role. As partnership staff and volunteers drew back the curtain on hidden older adults, the importance of its services and supports became more apparent. "That's what the eldest daughter used to do," Kershaw said. "We decided that if there is no one to play that function, then we will be that eldest daughter."
The partnership empowered "community liaisons" as coordinators for frail elders at risk in their homes. "We went back to the social worker idea from the turn of the century," Kershaw said, "where you don't just talk to someone on the phone. You do things. You go into their homes, look in the refrigerator and throw out moldy bread, cook a meal, take them to appointments."
During the grant period, some 400 frail seniors got help through community liaisons. In 2010, the Mary Gale Foundation, a local philanthropy, agreed to fund one community liaison full time to keep the often simple and nonmedical services available.
With major funding from Mary Gale and other community donors, the partnership also created a flexible spending fund to meet basic needs, an idea that has been replicated in two other towns.
Raking leaves and building trust. In the fall of year, the partnership organized a seasonal clean-up event and recruited volunteers from schools, businesses, the Red Cross and youth groups to do home maintenance chores for seniors.
Some 200 seniors got their lawns raked and weeds pulled that first year, but something even more important happened, Kershaw said. "By helping frail seniors with their lawn, you are establishing a safe environment to have a relationship with them," Kershaw said. "You are not in their home. You are not telling them they need to go to a doctor or to take a new medicine or that they should be in a nursing home. All you are doing is helping them with their lawn."
The second year, when the partnership offered to do a free safety survey in seniors' homes, most welcomed it. Volunteer handy people fixed—for free—anything found to be unsafe. "This approach to helping seniors—which is meeting them where they are at—was a huge paradigm shift for us and it has worked very nicely," Kershaw said.
Increasing understanding across generations. At one clean-up event the mayor noticed that few young people were among the volunteers. "Students need to understand what elders are going through," he said. He called the superintendent of schools and said, "I want you to talk with Seniors Count and come up with a concept."
The result was an experiential curriculum that allowed every senior high school student in the city to "walk a mile" in an older person's shoes. Among the exercises, students put on gloves and wore masks to experience the feeling of losing their acuity, sight and hearing.
Prisoner in her own home. Every partnership meeting begins with a story to show the service gaps that allow people to fall through the cracks. Dora's story had a happy ending.
Dora lived in a third-floor walk-up, rarely leaving her apartment. She had no family or friends, leaving television as her only companion. Several agencies, including Meals on Wheels and the local visiting nurse association, visited Dora, but no one coordinated her overall care. When the partnership found her, the television had broken and Dora was depressed. She was, in her own words, "a prisoner in my own home."
Using the flex fund to get Dora a new TV was the partnership's first order of business. Over the next several months, the partnership also found proper clothing so that she could visit the doctor, a dentist to provide new dentures, and a senior housing complex that provided Dora companionship and one congregate meal a day. "Once we find someone like Dora," Kershaw said, "she is never off our radar. She is still our client, even though we hardly do anything for her anymore."
"A three-legged stool needs rungs in between." Dora's story illustrates the three-legged stool of supports needed to maintain frail elders in the community. One leg is medical services, another is community social services, and the third is caregiver supports, such as one's children, spouse or neighbors. Kershaw says, "What we are saying with Seniors Count is, not only do you need the three legs of the stool, you need the rungs between the legs in order for that frail senior to really stay in the community successfully."
RWJF perspective. Community Partnerships for Older Adults was an eight-year, $28 million national initiative of the Robert Wood Johnson Foundation 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."