Supportive Services Programs in Naturally Occurring Retirement Communities. SUMMARY OF THE SITE VISIT TO UNITED JEWISH FEDERATION OF PITTSBURGH'S NORC PROJECT


The following information comes from discussions with 13 staff from the three agencies that operate the Pittsburgh NORC Demonstration Program under the auspices of The United Jewish Federation of Pittsburgh. The three agencies that jointly run the program are Jewish Family and Children's Services of Pittsburgh (JFCS), the Jewish Association on Aging (JAA), and the Jewish Community Center of Greater Pittsburgh (JCC).

In 2002, the three agencies jointly applied for and received a grant from the Administration on Aging (AoA) for $197,400. The AoA grant enabled the three agencies to set up a new, joint program designed to help older people remain in their own homes through development of individualized care plans based on a comprehensive, in-home assessment of need and provision of information about and referrals to appropriate community services. In certain emergency situations or in cases where a client demonstrated difficulty in seeking services on their own, program staff assisted clients in connecting to services. Using the second round of grant funding they received in federal fiscal year 2003, program staff plan to help connect more clients to services. This site visit focused on activities in the first year of funding under the AoA grant.

Description of the NORC and Its Residents

The NORC program serves adults age 60 and older living in the following contiguous Pittsburgh neighborhoods: Squirrel Hill North and South, Point Breeze, Regent Square, Swisshelm Park, Oakland, and Greenfield. As of July 31, 2003, the program had 60 clients.

According to the 2000 Census, Squirrel Hill South has the highest number of elderly men living alone at about 267 and the second highest number of elderly women living alone at 657 compared with all other Pittsburgh neighborhoods. About one-third of the elderly population living alone in Squirrel Hill and its adjacent neighborhoods has a low income, defined as less than 200 percent of the federal poverty level (FPL). Squirrel Hill also has the highest number of older Soviet Union immigrants in the Pittsburgh area. This population came to the area in the 1980s and is generally among the younger members of the elderly population. The neighborhood has also attracted Asians during the 1990s who were drawn to the universities and medical service opportunities in the area. The black population represents about 10 percent of the neighborhood's residents and is generally under age 65. With the exception of recent immigrants, most of the elderly population in Squirrel Hill has aged in place.

Squirrel Hill has been considered a Jewish neighborhood for the past 60 to 70 years. The Jewish community organizations in Pittsburgh are headquartered primarily in the southern part of Squirrel Hill in close proximity to one another. This area includes much of the lower income population; however, these organizations serve the entire neighborhood.

According to the 2002 Pittsburgh Jewish Community study, one-fifth of Jewish households in Greater Pittsburgh report needing assistance with an elderly relative, with one in ten reporting it was very difficult to get assistance. While use of social service organizations such as JCC, JFCS, and JAA among survey respondents in the Jewish community ranged between 5 and 26 percent, an overwhelming majority of users would use them again or recommend them to someone else (74 to 91 percent).

Squirrel Hill's physical environment creates barriers to independent living for the older population. The community has apartments, semi-detached housing, and detached homes that are often located on hills, have poor sidewalks, and require residents to mount many stairs to get to their homes. Not all apartment buildings have elevators. Since there is very little new housing, residents would have to renovate their homes to improve accessibility, and many cannot afford to do so. So accessibility remains a concern for these older people.

The neighborhood has four universities that partner with local agencies to run community programs such as JAA's Council Arts Program, which is a collaboration between JAA and Generations Together, a component of the University of Pittsburgh's Center for Social and Urban Research. The program brings older people at JAA's adult day services, assisted living, and other community sites together with high school students and resource artists to paint, quilt, write stories, and play music. The universities also have libraries, a music hall, lectures, and other cultural activities that help anchor the community. In neighborhoods adjacent to Squirrel Hill, there are "first rate" medical institutions, including hospitals and mental health services.

The neighborhood is self-contained in that people who are still mobile can get to shopping centers and have most of their needs met within a few blocks of their homes. Transportation from Squirrel Hill to the universities and downtown Pittsburgh is convenient but older people who have difficulties with mobility face problems getting transportation to doctors' appointments, shopping, etc. because getting to and then on and off the buses is difficult. There is a public transportation system called ACCESS, which is accessible but requires people to make arrangements and purchase tickets in advance. People also must spend a great deal of time waiting to be picked up and dropped off at their homes.

NORC Building Management and Communication with Residents

The NORC demonstration program does not have any formal links to particular apartment buildings in the community. Rather, it endeavors to serve the entire community. It communicates with community residents through a mailed monthly calendar; articles in the Jewish Chronicle (the weekly community newspaper); distribution of the NORC program brochure; regular, ongoing marketing efforts of the three partner agencies; and community education programs. For program clients--those seniors who have had a thorough needs assessment and who have been provided with a care plan listing contact information for appropriate community resources--contact is maintained via follow-up calls every two weeks and subsequent quarterly follow-up calls.

NORC Service Organizations

The United Jewish Federation of Pittsburgh contacted JAA, JCC, and JFCS about the opportunity to obtain the AoA grant. JAA takes the lead in coordinating the three agencies' NORC activities and its traditional service area is home and community services. JCC has its roots in the Jane Addams Settlement House, which served immigrants to the Pittsburgh area beginning over 100 years ago. Since World War II, the JCC has operated in Squirrel Hill, adding a branch in the southern suburbs of Pittsburgh in the late 1990s. JFCS provides a wide range of services for people of all ages and served 30,000 people in 2002. The JFCS is an accredited social services agency, which also provides services to people of all ages. The agency's $3 million annual budget comes from government, fees for services, foundations, contributions, donations, and the United Way. JAA began operations in 1993 and is the most recent entrant to Jewish community services. It consolidated the kosher home-delivered meals program, which had been operated by JFCS, with its adult day services program and added new programs, such as Sivitz Jewish Hospice. In addition to coordinating the NORC demonstration project, JAA operates residential and rehabilitation facilities and an information-and-referral phone service called ElderLink. Elderlink is a collaborative effort of the three service agencies. Residents can contact the NORC Demonstration Project by dialing the number for ElderLink.

The three agencies crafted a memorandum of understanding under which they operate the NORC program. They collaborated on developing and training the care teams (see below). The care plans the teams developed link clients to existing community resources and also help identify any gaps in service. These gaps are brought to the attention of the interagency NORC workgroup for problem-solving discussion and action planning. The program also links clients and caregivers, as appropriate, to support groups facilitated by the agencies.

The three agencies share responsibility for working with Unicentric, Inc., to design, develop, and continually refine the software used for the project's web-based information system. The system serves as the communications center, data warehouse, care plan preparation method, and project management center. JCC has the lead daily contact with Unicentric, Inc., working with the firm to coordinate the training of work group members in use of the information system. JAA has chief responsibility for preparing and distributing a monthly calendar that informs clients and families of NORC-related programs, educational events, and support group meetings.

Evolution of the NORC Service Program

Prior to development of the NORC Demonstration Program, JAA had a program called "Neighbors." Neighbors started in 1995 providing services in three large apartment complexes with at least 50 percent of the apartments occupied by at least one older person. Services include wellness, education, social services and activities, and monitoring of clients' physical conditions.

The three agencies noted the difficulty that some older people were having remaining independent in their homes. So they created the NORC Demonstration Program with the goal of helping people remain independent in their homes. They targeted people age 60 or older, establishing two interdisciplinary "care teams" each composed of one member from each agency to inform older people about available community services. The teams each have at least one clinical social worker. After the care team assesses the client's needs and available support network, they provide information to the client about services and programs that are available to help them meet these needs.

The NORC project was designed, in its early stages, to take advantage of the partner agencies' knowledge and experience to link clients to existing community services such as JAA's home and community services, JFCS's geriatric social work assessment and care management services, and JAA's senior adult programs. In the program's second year, activities will be expanded to include serving additional clients, following up on existing clients, and helping them to secure services.

Since the three agencies had rarely worked together in the past, they used part of the federal grant to fund an equine training program designed to promote group collaboration and team building. To meet the challenge of bringing staff together from three different agencies with different cultures, histories, and operating procedures, throughout the project's first year, project coordinators from the three agencies met regularly to continue working on and strengthening interagency collaboration. This collaboration is crucial to the project's success. These discussions will continue for the duration of the project.

Services Available to NORC Residents

The NORC Demonstration Program began sending three person care management teams to visit clients in their homes on December 1, 2002. Since that time, 60 clients have received home visits (as of June 26, 2003) with comprehensive assessments of their health, wellness, psychosocial skills, and mental attitude. The care team obtains assessment information during the home visit from the client, personal observations, a home check, and from family members or caregivers, when available. The team meets within one week after the assessment to develop a care plan for the client. The care plan specifies the community services that could benefit the client, including those provided by the three agencies, and provides contact information for the client to use to obtain services. A care management team member follows up with each client two weeks after the client receives the care plan and then quarterly thereafter to determine whether clients have contacted available community services.

There is a proposal under review for a new van service to overcome problems identified (and mentioned above) in getting less mobile clients, and community seniors generally, to doctors' appointments, shopping, to programs, etc. The review is being coordinated by the United Jewish Federation of Greater Pittsburgh, with major input from JAA, JFCS, and JCC.

NORC Service Program's Communication Methods

The program faced two communication challenges--interagency communications and communication with the community at large. The three collaborating agencies worked together to redesign and consolidate the agencies' existing assessment forms into one assessment tool that all could use. Although the project teams meet monthly, staff are located in different agencies and therefore need a way to communicate easily about clients. The agencies tackled this problem by hiring Unicentric, Inc., as noted above, to set up a virtual office and create uniform electronic formats for the redesigned assessment tools, ensuring that client's charts were accessible to all.

To recruit clients from the community, the program publishes articles in newsletters and calendars with information about the program and distributes these materials to social service agencies, doctors' offices, and other organizations. Clients have come to the program upon referral from these and other professionals. The program also held two public forums at different sites, including the JCC. Apartment building managers have also referred residents to the program and allowed the program to leave brochures in their buildings. Although the program does not have any special links to specific apartment buildings, it is currently exploring ways of developing such connections.

Despite these communication efforts, most of the program's initial clients were already connected to one of the three agencies in some way. Some participated in Neighbors, some were repeat callers to ElderLink, some were identified by JFCS geriatric social workers and other staff, and others participated in JCC activities.

NORC Service Program Challenges

The program has faced two major challenges, one internal and one related to program activities. The equine team building exercise, online communication, and, especially, regular meetings among the three agency project coordinators helped overcome the internal challenge of coordinating the activities of the three agencies. The activities-related challenge was that many clients failed to secure the community services that the care plan outlined. Barriers clients face in securing services include lack of an informal support system to facilitate connections, dementia, lack of money to pay for services (when payment is required), and an unwillingness to admit that they need help. The program is seeking to address this challenge through increased follow-up with clients.

NORC Service Program Quality Assurance and Outcomes

The only quality assurance activity is informal, positive feedback from clients. The program is considering implementing a client satisfaction survey during the second grant year to provide more consistent feedback.

NORC Service Program's Funding Sources

Funding sources for the program are the AoA grant and in-kind contributions from the three agencies. The project's total funding for 2002 through 2003 was $328,271 ($197,400 federal, the remainder in-kind). The program has been granted $250,000 in U.S. Administration on Aging funds for 2003 through 2004, with a total project cost of $334,342.

Future Plans and Recommendations

The Pittsburgh NORC Demonstration Project has already determined that it will maintain follow-up contact with the 2003-2004 clients to ensure that they are actually connecting with the services recommended in their care plans. The project also plans three community-oriented informational programs that will target families of elderly individuals and one program for social service agencies interested in what the demonstration project has accomplished and learned. Partnership opportunities with these agencies will also be explored.

NORC staff said that service programs cannot simply supply information to clients about available programs; staff must help clients access those programs. Unless there is a crisis, clients and families do not always recognize the benefits to be gained from participating in the service programs identified for them and so may not take action. And sometimes the family and the client have different agendas. For example, the family may want elderly clients to move into protected settings, while the elderly might prefer to remain in their home. NORC programs might well consider developing information programs for family members to bridge this gap.

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