Bridging Elder Care Networks
of the Life: Act 2 Partnership

For information, contact:
Mark LeMaire
904-390-3234
markl@uwnefl.org

Chapter 1: How did this Partnership get started? How are they structured?  What have they been doing?

Chapter 2: What Difference Did the Community Partnership Make Here?

Chapter 1: How did this Partnership get started? How are they structured?  What have they been doing

I. WHY Did the Partnership Happen Here?

In Northeast Florida, the five county region that includes Baker, Clay, Duval, St. Johns and Nassau counties, is expected to experience a 31% growth in people over 60 years of age in the five years from 2005 to 2010. As a result, the United Way of Northeast Florida adopted aging as a major priority of its community planning process for the next decade and participated in the AdvantAge project to gain additional information about older adults in the region. The Bridging Elder Care Networks Life Act2 Partnership (BECN) emerged from this early work and applied for a CPFOA grant. Early members of the BECN Partnership included both public and private funders of senior services in the community, local hospitals, and an earlier health care access partnership titled JAX Care.

Demographics & Findings:

• This region contains some of the densest populations of older adults in the country, averaging 15.2% of the total population (even higher in Duval County which has 146 elders per square mile!).
• Official poverty rates for older adults hover between 9% and 12%, but many more in the region are near-poor or low-income, falling far below the median income of $40,000.
• Public funding for community-based service providers remained flat or declined as demand grew, and consequently waiting lists for services expanded. Because publicly funded programs tended to target the frailest elders and those with low incomes, little was available to people of moderate or middle incomes except privately paid or volunteer supports.
• Surprisingly though, in more remote areas, publicly funded services were under-utilized due to the lack of awareness about the programs; and these programs were threatened with funding cuts.
• Area hospitals reported a backlog of elders remaining unnecessarily hospitalized or being quickly re-admitted following discharge due to patients’ difficulty in accessing needed services post-discharge.

Data Collection: The BECN Partnership held 12 focus groups for older adults, six meetings with providers of long term care services, four workshops with teams of leaders for the major not-for-profit health systems; and solicited input from the public through the Mayor’s Neighborhood Summit, news articles and TV appearances of Partners. A survey of frail homebound elders built on the earlier findings of 2 other surveys and the Partnership found that results were consistent with the community input. At a half day planning forum, findings were shared that participants shaped into priorities and implementation strategies to move forward.

II. Getting Started: What Vision, Goals and Structure emerged?

Vision: “The idea….was to create a new approach to the second half of life. This refers to not only how we age, but how we as a community regard our seniors….engage them and utilize them as valuable community resources…and, how we improve the systems and organizations they contact for services.” Goals: 1) to elicit a culture shift in the way the Northeast Florida community views and values seniors; 2) to integrate medical admission and discharge processes with the community’s social service system; and 3) to strengthen the continuum of services available to the community’s seniors.

Structure: The United Way of NE Florida created the Life: Act 2 Partnership Council to provide community leadership for the challenges and opportunities of a rapidly increasing senior population. The Community Partnership for Older Adults grant was implemented through the Bridging Elder Care Networks Task Force and created four workgroups to carry the work forward:

• The Education workgroup focused on public awareness and changing the perceptions about older adults,
• The Hospital Workgroup focused on hospitals’ self assessments and plans for practice changes,
• The NEFIN (Northeast Florida Information Network) Expansion to the Elder Care workgroup focused on guiding the work of sharing the health/long-term-care shared electronic record and medical case management information system with the Area Agency on Aging and JAX Care.
• The Fundraising workgroup worked on the long term sustainability of the BECN Partnership.

III. WHAT: Implementing initiatives to address issues. What did they do?

Priority 1: Hospitals Serving Elders Better – (Support health providers in making hospital specific system changes which improve delivery of health care to older consumers.)

• Two area hospitals reviewed how “elder friendly” their institutions were using a self assessment survey developed by the partnership. The Baptist Medical Center created a new elder care services office powered by staff and volunteers specifically to focus on the needs of their older patients and make follow up calls post-discharge..
• The hospitals also created task forces to monitor elder care issues within their facilities and recommend changes on an ongoing basis based on customer satisfaction surveys

Priority 2: Elder Systems Improvements – (Decrease the number of days older adults unnecessarily stay in a hospital due to the unavailability of or their ineligibility for long term care or independent living support services.)

• An Advocacy & Transitional Care Management Program designed by the Partnership, has successfully placed 2 part-time Eldercare Advocates in hospitals to assist older adults as they transition home following often very fast]discharges. These advocates assisted 380 patients over 60 years of age, seeing them within 48 hours of discharge to help them locate purchased services, information and support. 85% of those receiving this support were not required to be re-admitted within 30 days, and 90% said they received assistance they would not have gotten without the Elder Advocate. New bridges have been built between hospitals and community based services to create more seamless transitions home.
• A new Falls Prevention program is underway, due to funding received from Brooks Rehabilitation Hospital. The Elder Advocates are screening high risk elders using a new questionnaire and are distributing a newly created falls-prevention fact sheet.

Priority 3: An Informed Public – (Increase the knowledge of the community as a whole, particularly older adults and/or their caregivers, about availability/accessibility of health and long term care information and services.)

• 37,000 Quick Reference cards for seniors were distributed over the five counties. Another 7250 were sent to physicians’ offices, businesses, grocery stores and libraries.
• A two stage public information campaign about available senior services in Baker County helped increase usage of underutilized programs providing home delivered meals, homemaker services, personal care, and emergency alert programs so that their funding was not reduced and permanently lost.
• The newly created Discharge information packages were distributed to 250 elders.

Priority 4: Better Quality through Education

• Twenty providers held a Geriatric Education Strategy Café, discussing the caregiver workforce education available and needed; attendees explored the possibility of sharing access to each other’s training opportunities between the employees of all organizations. A concept paper of recommendations will be discussed and reviewed in summer, 2008.

Priority 5: Creation of an effective Partnership

• 35 Partnership members were recruited.
• A blog web page was developed through which work groups and partners communicate so everyone can stay abreast of work, assignments and progress.
• Michael Korn, Partnership Chair, was invited to address the Duval Legislative delegation about the Partnership in October 2006; and Partnership representatives presented at the state Conference on Aging in August 2007 about “Convening community leaders to address senior issues.”

Chapter 2: What Difference Did the Community Partnership Make Here?

Coming soon!