Seniors Count Community Connections (SCCC)
The Seniors Count Community Connections project was implemented by Easter Seals New Hampshire in the Greater Manchester service area with four medical partner organizations: Hillsborough County ServiceLink Aging and Disability Resource Center (ADRC); Catholic Medical Center, Elliot Senior Health Center, and Dartmouth-Hitchcock Manchester.
The goal of the Seniors Count Community Connections (SCCC) project was to create and implement a replicable person-centered model to enhance coordination among the three silos of care (medical, community/social services, and caregiver), using a â€œthree-legged stoolâ€ as a metaphor to show that all three are necessary to support the health and independence of older adults. To achieve this goal, SCCC embedded Community Liaisons within the partner organizations to provide long-term care coordination, referrals, and other supportive services to frail seniors that are most at risk, including home-based medical and non-medical services, Meals on Wheels and food pantries, home maintenance and repair, and social and recreational activities.
Specific accomplishments of the Seniors Count Community Connections (SCCC) project include:
- Services were provided to 146 frail older adults, many of whom had recent hospitalizations, emergency department use, falls, and depressive symptoms, as well as housing and food insecurity, inadequate social support, and inadequate financial resources.
- Community Liaisons addressed the range of issues identified in the SCCC screening matrix (see below), including finance, life skills, health care, home and safety, mental health, social support, and mobility.
- Clients were linked to the ServiceLink ADRC, area food banks, transportation services, assistive technology, homemaker services, assistance with shopping, Meals on Wheels, volunteer home visitors, fix-it services for minor home repair, and mental health care.
- Among 62 clients with six month follow-up assessments, there were noticeably decreased levels of need in five domains: financial resources, housing and home safety, food and nutrition, healthcare, and family relationships/social support.
- Through supplemental funding, SCCC was able to provide needed dental services, including fillings, extractions, and dentures to frail older adults.
- Seniors Count 2012 video
- Seniors Count Community Connections Presentation by Arlene Kershaw (Senior VP of Easter Seals New Hampshire and Seniors Count Project Director) and Sue Fox (Clinical Asst. Professor, Center on Aging and Community Living/UNH and Seniors Count Evaluator)
- Seniors Count Three-Legged Stool
- The SCCC Preliminary Screening Assessment Matrix helps assess client eligibility and need, develop care plans, and measure individual level of progress with respect to independence
Seniors Count, Easter Seals New Hampshire
Director, Caring Companions, Easter Seals New Hampshire
Project Manager, Seniors Count
Click here for a detailed case study of the CIAIP Seniors Count project, including accomplishments, challenges, and lessons learned.