Supporting Aging in Place in Subsidized Housing:

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Supporting Aging in Place in
Subsidized Housing:
An Evaluation of the WellElder Program
Alisha Sanders, MPAff and Robyn Stone, DrPH
January 2011
Funding for this project was provided by the SCAN Foundation. The views presented here are
those of the authors and do not necessarily represent the official statements or views of the
funders.
The SCAN Foundation is an independent, not-for-profit charitable foundation dedicated to longterm services and supports that keep seniors self-sufficient, at home and in the community. As
the only foundation with a mission focused exclusively on long-term care, The SCAN
Foundation is taking action to develop and support programmatic and policy-oriented
recommendations and solutions that address the needs of seniors and influence public policy to
improve the current system.
Supporting Aging in Place in Subsidized Housing: An Evaluation of the WellElder Program
2011, LeadingAge and the LeadingAge Center for Applied Research. All rights reserved.
LeadingAge Center for Applied Research
2519 Connecticut Avenue, NW
Washington, DC 20008
202-508-1208
www.LeadingAge.org/reserach
The LeadingAge Center for Applied Research, formerly IFAS, bridges practice, policy and
research to advance high-quality health, housing and supportive services for America’s aging
population. The Center’s three signature objectives are to advance quality of aging services,
develop a high-performing workforce and enhance resident options through services and
supports. Through applied research, the Center creates an evidence-base to improve policy and
practice. LeadingAge is an association of 5,500 not-for-profit organizations dedicated to
expanding the world of possibilities for aging.
Table of Contents
Chapter 1 – Introduction ................................................................................................................ 1
Statement of the Problem .......................................................................................................... 1
Rationale ..................................................................................................................................... 2
Study Overview ........................................................................................................................... 3
Study Methodology..................................................................................................................... 3
Study Limitations and Challenges ............................................................................................... 6
Chapter 2 – Housing Communities and Resident Characteristics .................................................. 8
Housing Communities ................................................................................................................. 8
Resident Characteristics.............................................................................................................. 9
Resident Incidents..................................................................................................................... 16
Resident Move Outs.................................................................................................................. 17
Chapter 3 – WellElder Program Implementation ......................................................................... 18
Program History ........................................................................................................................ 18
Program Elements..................................................................................................................... 18
Chapter 4 – Study Findings ........................................................................................................... 35
Program Benefits ...................................................................................................................... 35
Differences between Members and Non-Members................................................................. 43
Program Participation ............................................................................................................... 48
Chapter 5: Conclusions and Recommendations ........................................................................... 52
WellElder Implementation ........................................................................................................ 52
Impact of the WellElder Program ............................................................................................. 52
Potential for Replication ........................................................................................................... 54
Recommendations for Improvement ....................................................................................... 54
Concluding Remarks.................................................................................................................. 59
References .................................................................................................................................... 60
Appendix A: Group Education Sessions ........................................................................................ 62
Appendix B: Resident Self-Administered Survey Results, by Membership .................................. 63
List of Tables and Exhibits
Table 2.1 Housing Property Characteristics .................................................................................................. 8
Table 2.2: Resident Age, Gender and Residential Status ............................................................................ 10
Table 2.3: Resident Race and Ethnicity ....................................................................................................... 10
Table 2.4: Resident Place of Birth and Language ........................................................................................ 11
Table 2.5: Resident Receiving MediCal ....................................................................................................... 11
Table 2.6: Self-Reported Health Status ....................................................................................................... 11
Table 2.7: Self-Reported Health Conditions................................................................................................ 12
Table 2.8: Percent of Residents Reporting Multiple Chronic Health Conditions ........................................ 12
Table 2.9: Percent of Residents Troubled by Pain ...................................................................................... 13
Table 2.10: Percent of Residents Reporting ADLs and IADLs...................................................................... 13
Table 2.11: Resident Reported Types of ADLs and IADLs ........................................................................... 14
Table 2.12: Resident Reported Falls ........................................................................................................... 14
Table 2.13: Resident Reported Emergency Room Visits, Hospital Stays and Outpatient Surgeries........... 15
Table 2.14: Resident Reported Prescription Medications .......................................................................... 15
Table 2.15: Support from Family, Significant Others or Friends ................................................................. 16
Table 2.16: Reported Level of Assistance Provided by Family, Significant Others or Friends .................... 16
Table 2.17: Resident Incidents .................................................................................................................... 17
Table 2.18: Resident Move Outs ................................................................................................................. 17
Table 3.1: Staffing Pattern .......................................................................................................................... 19
Table 3.2: WellElder Program Membership................................................................................................ 20
Table 3.3: Non-Member Reasons for Not Joining WellElder Program* ..................................................... 21
Table 3.4: Potential of Joining Program in Future ...................................................................................... 21
Table 3.5: Number of Member Visits to WellElder Staff ............................................................................ 23
Table 3.6: Percent of Participants with At Least One Visit to WellElder Staff ............................................ 23
Table 3.7: Average Number of Visits to WellElder Staff per Member ........................................................ 24
Table 3.8: Percent of Members with At Least Five Visits to WellElder Staff .............................................. 24
Table 3.9: Frequency of Services Provided by Service Coordinator ........................................................... 27
Table 3.10: Frequency of Services Provided by Health Educator ............................................................... 30
Exhibit 1: Examples of Residents Assisted through the WellElder Program............................................... 33
Table 4.1: How the WellElder Program Helps Residents* .......................................................................... 41
Table 4.2: Differences between WellElder Program Member and Non-Member Characteristics ............. 44
Table 4.3: Differences between WellElder Program Member and Non-Member Service Use .................. 45
Table 4.4: Number of Resident Incidents ................................................................................................... 47
Table 4.5: Percent of Residents Experiencing Incidents ............................................................................. 47
Table 4.6: Resident Move Outs and Destination ........................................................................................ 48
Chapter 1 – Introduction
The goal of this study is to evaluate the WellElder Program, a program developed and
implemented in four low-income senior housing properties in the San Francisco bay area
operated by Northern California Presbyterian Homes and Services (NCPHS) and Bethany Center
Senior Housing. The program pairs a nurse health educator and resident service coordinator to
help elderly residents maintain independent living by offering wellness and health education,
health monitoring and individualized service coordination. The study is intended to add to the
evidence base of the potential benefits of integrating health and supportive services into
subsidized housing for older adults.
Statement of the Problem
Advanced age and low income place older adults at greater risk for chronic illness and disability,
and consequently in greater need of health and long-term care services (Redford and Cook,
2001). For example, individuals age 85 and older are seven times more likely to need help with
basic personal tasks like getting around the house, dressing, bathing, eating and going to the
toilet than individuals age 65 to 75 (National Center for Health Statistics, 2007). Four out of five
older adults age 65 and older have one or more chronic health conditions such as hypertension,
heart disease or arthritis that may contribute to disability, while half experience at least two
(Centers for Disease Control and Prevention, 2007). Multiple chronic diseases, along with poor
health status and functional limitations, are more prevalent among the lower-income elderly.
Individuals with multiple chronic conditions are particularly vulnerable to suboptimal care
(Vogeli, 2007). They tend to use services more frequently and a greater array of services, which
makes coordination of care more difficult. The number of different physicians seen annually by
the average Medicare patient with a chronic condition ranges from four for persons with one
condition up to 14 for persons with five or more conditions. As the number of providers involved
in patients’ care increases, patients are likely to find it increasingly challenging to understand,
remember and reconcile the instructions of those providers. Because persons with multiple
chronic conditions take more medications on average, they are more likely to suffer adverse drug
events. Having multiple chronic conditions also makes it more challenging for patients to
participate effectively in their own care.
Many people 65 and older have significant difficulty reading and comprehending medical
information that is pertinent to their health. In one study of enrollees in a Medicare managed care
plan, more than one-third of study participants had inadequate or marginal health literacy and the
prevalence was found to increase steadily with age (Gazmararian et al., 1999).1 Individuals with
1
Health literacy is not limited to the ability to read, but also includes the ability to understand instructions on
prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and
the ability to negotiate complex health care systems. It requires a complex group of reading, listening, analytical,
and decision-making skills, and the ability to apply these skills to health situations (National Library of Medicine,
2010).
Evaluation of the WellElder Program
1
lower incomes are also more likely to have limited health literacy (Office of Disease Prevention
and Promotion).
Health literacy affects people’s ability to navigate the healthcare system, including filling out
complex forms and locating providers and services, share personal information such as health
history with providers and engage in self-care and chronic-disease management (Office of
Disease Prevention and Health Promotion). Low health literacy has been linked to lower use of
preventative services (Scott, Gazmararian, Williams and Baker, 2002). It has also been found to
be linked to lower self-rated health status and higher rates of hospitalization and emergency
room use (Cho, Lee, Arozullah and Crittenden, 2008).
An older adult’s inability to manage their health and functional needs not only potentially
endangers their ability to remain safely independent in their own home, but the high utilization of
health care services increases the cost burden on both the individual and the Medicare and
Medicaid systems.
For several years, policymakers, service providers and aging advocates have sought new ways of
organizing long-term care supports in a manner that is both desirable and affordable. The
emphasis has been on shifting away from institutional services and expanding opportunities for
older adults to receive the assistance they need in the community. More recently, there has also
been greater focus on strengthening care delivery options to help older adults with chronic
conditions better manage their diseases and their transitions across settings, with the goal of
improving their health outcomes and quality of life while lowering costs.
One promising option for helping meet these goals is subsidized senior housing communities.
With their economies of scale, the properties provide a potentially efficient platform to reach a
concentrated number of individuals who could benefit from better self-care knowledge,
monitoring and referral to appropriate community services. Interventions that link health and
supportive services to low-income senior housing may assist elderly residents to better manage
their health, decrease their use of emergency room and hospital services and maintain
independence in their apartments for a longer period of time thus delaying or preventing transfers
to a higher level of care.
Rationale
About two million low-income older adults, mostly single women in their mid 70s to early 80s,
live in independent, largely multi-unit federally subsidized housing—more than the number who
live in nursing homes (Wilden and Redfoot, 2002). Findings from a range of studies indicate that
significant numbers of these residents are aging and experiencing chronic illnesses and/or
disabilities.
According to the U.S. Department of Housing and Urban Development, the median age of
Section 202 residents in 2006 was 74 years old and almost one-third of residents were 80 or
older (Haley and Gray, 2008). In an analysis of the AHEAD Wave 2 survey (Asset and Health
Dynamics Among the Oldest Old), Gibler (2003) found that older subsidized housing residents
reported being in poorer health than unsubsidized renters and experienced more chronic health
conditions. Gibler’s study also indicated that subsidized housing residents have a significantly
Evaluation of the WellElder Program
2
higher number of difficulties carrying out basic activities of daily living (ADLs) and
instrumental activities of daily living (IADLs) than unsubsidized renters.2 Using data from the
2002 American Community Survey, Redfoot and Kochera (2004) found that older renters
receiving subsidies were twice as likely to experience activity limitations as home owners. Over
half reported limitations in activities such as walking and climbing stairs, compared to one
quarter of older homeowners. A third reported difficulty with shopping or going to the doctor,
twice that of older homeowners. Estimates prepared for the U.S. Commission on Seniors and
Affordable Housing (2002) show that one third of subsidized renters have some difficulty with
ADLs and 12 percent have a mental or cognitive disability that interferes with everyday
activities. A 2006 survey of managers for Section 202 and Low Income Housing Tax Credit
(LIHTC) properties indicated that a significant portion of Section 202 residents (36 percent) and
LIHTC residents (38 percent) are frail (have difficulty walking or performing everyday tasks) or
disabled (Kochera, 2006).
Together, the above studies suggest significant numbers of older adults with chronic illness and
disability live in subsidized housing settings, many of whom are highly likely to have difficulty
managing their health care needs and have unmet needs for assistance with basic activities.
Interventions that link health and supportive services to low-income senior housing may assist
elderly residents in remaining healthier and more independent in their apartments for a longer
period of time, minimize ER and hospital visits and delay or prevent nursing home transfers.
Study Overview
The study was conducted by the LeadingAge Center for Applied Research. Funding for the
project was provided by The SCAN Foundation.
The study had three objectives:
• Objective 1: Describe the components of the WellElder Program and understand its
implementation, including how consistently the program is implemented across the 4
sites.
• Objective 2: Understand program users and non-users and the factors associated with the
decision to enroll.
• Objective 3: Understand the perceived benefits of the program to the residents, their
families, the staff and the properties.
Study Methodology
The formative evaluation employed a multifaceted, qualitative and quantitative methodology.
Data collection strategies included:
• a self-administered resident survey
• focus groups
• structured interviews
2
ADLs refer to basic activities of daily living such as bathing, dressing, eating, going to the toilet and getting around
the house. IADLS refer to instrumental activities of daily living such as shopping, housekeeping, taking
medications, using the phone etc.
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•
services provided, resident incident and resident move out tracking system
The evaluation was conducted over a one-year period between July 2009 and June 2010, with
service use, incident and move out data tracked for an eight-month period from October 2009
through May 2010. The study was reviewed by an Institutional Review Board to ensure all data
collection activities met guidelines for human subject protection and was granted an exempt
status. Each data collection component is described in more detail below.
Resident Survey
A self-administered survey was distributed to all residents in the four participating properties.
Two survey versions were created, one for WellElder program members and another for nonmembers. Each survey contained two sections. The first section was identical in both surveys and
asked residents about their health and functional status, their health service use, the support
network and their service use. The second section differed in each survey, asking program
members about their use of and benefits from the program and asking non-members why they
chose not to participate in the program. Membership status was identified by the WellElder staff
and any mention of the term “WellElder” in the survey was clarified as the “program in your
building where you receive assistance from the service coordinator and nurse.” The appropriate
survey was distributed to each resident’s mail box and residents returned completed surveys to a
secure box in a common location in the property. The surveys were anonymous and confidential
and contained no personal identifiers. Surveys were translated into five languages, including
Russian, Chinese, Korean, Vietnamese and Spanish. Assistance completing the survey was
provided to residents requesting help. To help encourage a higher response rate, residents in each
property were entered in a drawing for a gift card upon completing the survey. Response rates
for the survey were as follows:
Surveys
Completed
Total
Residents
Response
Rate
Property 1
92
258
35.7%
Property 2
84
217
38.7%
Property 3
140
257
54.1%
Property 4
89
156
56.4%
TOTAL
404
888
45.5%
Interviews
Structured, one-on-one interviews were conducted with the service coordinators, health
educators, property managers and the NCPHS Director of Resident Services. These formal
interviews were supplemented with several informal conversations to gain additional information
and clarity about the WellElder program. Two rounds of interviews were completed with the
service coordinators and health educators in each of the four housing properties. The first set of
interviews focused on understanding how the program operates. The second round focused on
the perceived benefits of the program to the residents, the housing property and others. The
property manager of each housing site was also interviewed about the perceived benefits of the
program to residents and the housing property. The NCPHS Director of Resident Services was
interviewed about the history and development of the program, program operations and
perceived benefits of the program.
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Focus Groups
Focus groups were conducted with WellElder program members and non-members. Membership
status was identified by the WellElder staff in each property. Groups were conducted in English,
Russian and Chinese to ensure that the experiences and opinions of non-English speakers were
captured. The purpose of the focus group with program members was to understand what type of
assistance they receive from the WellElder program, what they think are the benefits of the
program, what difference they believe it would make if the program were not available and any
ways they would change the program. The focus group with non-members attempted to
understand why they do not participate in the program, if they perceive there are any benefits of
the program, where they currently get assistance with their health and wellness needs and
whether they ever foresee participating in the program. A total of 11 focus groups were held, six
with program members (two in English, two in Chinese, and two in Russian) and five with nonmembers (three in English, one in Chinese and one in Russian). Residents were compensated $20
for their participation.
Services Provided, Incident and Move Out Tracking
Data was tracked over an eight-month period from October 2009 to May 2009 in the three areas
described below. This information was partially collected by the WellElder staff and the study
team worked with the WellElder staff to develop formal data collection forms that added
additional elements to the data already collected by the staff. The study team provided training
and an instruction guide on the data collection processes. At the beginning of the study, the
WellElder staff assigned each member and non-member an ID number. All data was tracked by
those ID numbers so that no personal identifiable information was shared with the study team.
All data was provided to the study team on a monthly basis.
1) Services provided by the service coordinator and health educator - The service
coordinator and health educator in each building tracked the type of assistance they
provided to WellElder program participants. The tracking form used was based on a prior
form used by the WellElder staff. This was done to help enhance the consistency of the
data since it was a form and method they were already familiar with. WellElder staff
tracked the date the participant was seen, the amount of time spent directly with the
resident, the amount of collateral time spent doing follow-up or other activities related to
that visit and the types of assistance provided during the visit. The types of services that
were tracked can be seen in Table 3.9 (service coordinator) and Table 3.10 (health
educator). Only services related to the WellElder program, i.e. health and wellness, were
tracked by the service coordinator. For example, if the service coordinator helped a
resident receive a rebate from an energy assistance program for low-income seniors, that
service would not be captured for this study.
2) Resident incidents – The WellElder staff tracked significant incidents, including falls,
911 calls, emergency room visits, hospital stays and nursing home stays. This data was
tracked for both WellElder members and non-members. WellElder staff identified the
incidents through incident reports provided by the property management, security logs, or
through direct knowledge of resident events.
3) Resident move outs – The WellElder staff tracked resident move outs and the reason for
move out. Reasons included moving to another senior subsidized apartment community,
Evaluation of the WellElder Program
5
to another apartment property, in with family, to a residential care for the elderly/assisted
living facility, to a nursing home or death. WellElder staff identified move outs and their
reason from property management.
Data Analysis
Study data was analyzed through a combination of qualitative and quantitative methods.
Findings from both the quantitative and qualitative techniques were interwoven to provide a
comprehensive analysis.
Qualitative data came from the resident focus groups and structured and informal interviews. A
deliberate, inductive process was employed to analyze the data—moving from individual
interview and focus group write-ups to site level and group summaries and, ultimately, to a
synthesized set of findings across the properties. For the focus groups, the note taker and
moderator debriefed shortly after each group and took notes to record key themes. When all
focus groups were completed, the study team identified key themes across all the groups and
across each housing property. The same process was used with the structured interviews.
Quantitative data were collected from the resident self-administered survey and the services
provided, resident incident and resident move out tracking process. All data were entered into
Excel and imported into SAS for data analysis. For the resident survey, various statistical tests
were run, including basic descriptive statistics establishing means, medians, and frequency
distributions by individual housing properties and program members and non-members. Fisher’s
exact tests were used to compare members versus non-members in categorical variables and Ttests were used for numeric variables. Descriptive statistics were calculated to describe the
frequency of service and time spent on services for the various types by property and by
race/ethnicity. Event rates and incidence of various health events were calculated by property
and membership status.
Study Limitations and Challenges
Every research study faces limitations and challenges. In this study, limitations are defined as
issues that are inherent in the type of research being conducted. Challenges are defined as issues
that arose during the course of conducting the study that are barriers to achieving study
objectives and which were (or were not) overcome.
Two major limitations are noted. Although the study compared users with non-users, a control
group was not available, which prevented examining the impact of the program on resident
outcomes. The study should be viewed as descriptive and providing information on possible
relationships that could be explored with additional resources to support a more rigorous design.
In addition, focus group participants who provided an evaluative perspective on the WellElder
program were told beforehand about the general topic area that would be discussed. The
residents who agreed to participate were self-selecting or recommended by the WellElder staff—
as is true of many focus group efforts. Although the results from the focus groups were analyzed
in conjunction with other data sources, the possible introduction of bias based on focus group
makeup must be acknowledged.
Evaluation of the WellElder Program
6
Two primary challenges were encountered in the data collection process. First, service use data
was tracked by the individual service coordinators and health educators in each of the four
housing properties. WellElder staff visits with residents can address multiple issues and it is
possible that all service coordinators and health educators did not categorize the types of
assistance they provided similarly. Most areas of assistance are distinct but some are slightly
more subjective. Although the study team provided guidance for all WellElder staff on the data
collection process, there is still a possibility of some inconsistent tracking across properties.
Additionally, service coordinators were asked to track only those services that were considered
“WellElder” services and not all services they provide. WellElder services are ones that have a
health and wellness-related element. Although guidance was given to service coordinators about
the types of services to track and not track, they still individually decided what services to
record. It is possible that there may be some inconsistencies across the service coordinators in
what services they did or did not record. To maximize uniformity and ensure the quality of the
data, the study team reviewed the data submitted monthly from the service coordinators and
health education for potential recording discrepancies and had frequent conversations with them
to help ensure consistency.
Second, the data on resident incidents (falls, 911 calls, ER visits, hospitalizations and nursing
facility stays) may be incomplete. Because the properties are independent housing communities,
they do not track the coming and going of residents and residents are not required to check in
with the property. All of the properties have 24-hour onsite security who see everyone coming
and going into the building. In addition, all residents have emergency notification systems in
their apartments to notify security when they have an emergency and need assistance. Most
transfer in and out of the building due to one of the incidents being tracked would have been
recorded by the security who then create incident reports. In addition, residents often alert the
WellElder staff when they have had an incident, and neighbors often do the same. There is a
chance, though, that an incident may have gone unknown to the property or WellElder staff. For
example, a resident’s doctor may send them directly to the ER from an appointment in their
office.
Evaluation of the WellElder Program
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Chapter 2 – Housing Communities and Resident Characteristics
The WellElder program operates in four senior housing communities in the San Francisco Bay
and San Jose areas. Three of the properties—Eastern Park Apartments, Western Park Apartments
and Town Park Towers—are operated by Northern California Presbyterian Homes and Services
for the Aging. The fourth—Bethany Center Senior Housing—is a free-standing community.
Each is an affordable independent rental property designed for low-income seniors aged 62 and
above. Each property has articulated a philosophy of helping to support their residents to meet
their health and supportive service need and to safely age in place.
Housing Communities
The four properties were developed through funding mechanisms from the U.S .Department of
Housing and Urban Development. One property was developed through the Section 202
program, which is the only federal financing source specifically for senior housing. A Section
202 property receives a construction loan plus project-based rental subsidies that limit the
tenant’s monthly rent payment to 30 percent of their income. Qualified tenants generally must be
at least 62 years old and have incomes less than 50 percent of the area median income. The other
three properties were developed through the Section 236 program. Section 236 is a mortgage
interest subsidy program for all age levels, but properties can be designated for elderly
households. Tenant eligibility is limited to households earning under 80 percent of the area
median income. HUD sets a basic rent and tenants must pay either the basic rent or 30 percent of
their income, whichever is higher. However, the property may also receive some form of rental
assistance subsidy, such as Section 8, that limits the tenant’s monthly rent payment to 30 percent
of their income. These rental subsidies may cover all or a portion of the units in the property.
Table 2.1 describes the type of subsidy mechanism through which each property was developed,
the number of units and residents in each property and the median income of the resident
population.
Table 2.1 Housing Property Characteristics
Property 1
Property 2
Property 3
Property 4
Section 202
Section 236
Section 236
Section 236
Number of Units
201
182
216
122
Units with Project-based Rent
Subsidies*
201
115
173
109
Number of Residents**
270
220
270
157
$9,772
$14,700
$15,312
$10,288
Subsidy Type
Median Resident Income***
*Some residents in units that do not have an attached project-based rental subsidy may have a tenant-based Section 8
voucher from the City of San Francisco.
**At start of data collection period.
***Information provided by each housing property from their tenant eligibility system.
Evaluation of the WellElder Program
8
Resident Characteristics
Residents in all four housing properties were asked to complete a self-administered survey that
asked about their background, health and functional status, health services use and support
network. The following description of residents is drawn from the survey responses.
Summary of Resident Characteristics
The median age of the housing residents is 78 years with the youngest age 38 and the oldest age
95. Sixty-three percent of the residents are female and three out of five live alone.
The resident population is extremely diverse. Only one third of the residents are white, ranging
from 14 percent to 58 percent across the four properties. The largest group—58 percent—is
Asian. A little less than one in 10 are Hispanic (ranging from four percent to 21 percent across
the properties) and a little less than 3 percent are black or African American (ranging from one
percent to six percent). Only 14 percent of the residents were born in the United States and only
16 percent report English as their first language. The majority of the resident population across
the four properties is of Chinese or Russian origin.
With respect to their health status, 71 percent of the residents indicated that their health was fair
to poor. Over half (54 percent) reported having three or more chronic conditions with the three
top illnesses identified as high blood pressure, arthritis and heart problems. A little over one third
of the residents reported having a memory-related disease and 28 percent reported emotional or
psychiatric problems. The latter two conditions are particularly likely to be underestimated given
that they are self-reported and subject to concerns about stigma or lack of knowledge. Three out
of four residents across all four properties reported that they are troubled with pain, with a little
less than one in four indicating that they are in severe pain. On average, residents reported taking
six prescription medications, ranging from none to 21.
In terms of functional status, over one half (55 percent) of the residents report that they have
limitations in one or more activities of daily living. More than one third (35 percent) have fallen
at least once over the past 12 months.
With respect to service use, almost one third of the residents reported using the emergency
department over the past year. One in five had been hospitalized at least once and close to one in
four had received out-patient surgery.
The majority of residents reported the availability of some level of social support. Eighty-seven
percent indicated that they had someone in the area to call if necessary. Almost one half
indicated that they received calls from someone in their social network on a daily basis; one out
of five reported having daily visits. On the other hand, 30 percent of the residents received
visitors once a month or less. When asked about assistance from their social networks, 11
percent reported that they did not need any help. At the opposite extreme, almost one third
reported receiving considerable assistance.
Evaluation of the WellElder Program
9
It is possible that the survey results may overestimate residents’ health level and understate their
functional status to some degree. Potentially some of the residents who did not participate were
the frailer residents who might have more difficulty completing the survey. It is also possible
residents may not have accurately disclosed their health status, health conditions or level of
disability and need for assistance. This may reflect residents’ denial about their health status and
functioning level or fear that revealing information about their needs will jeopardize their ability
to remain in an independent living setting.
Demographics
As shown in Table 2.2, the median age of residents completing the questionnaire in the four
properties is approximately 78 years old. Considering only residents age 62 and over, the median
age is 79 years old. Between 58 and 69 percent of residents completing the survey are female.
This proportion is slightly smaller than is generally seen in affordable senior housing properties,
where an average 80 percent of residents are females. The survey also revealed fewer residents
who live alone in comparison to the average affordable senior housing property.
Table 2.2: Resident Age, Gender and Residential Status
Property 1
Property 2
Property 3
Property 4
Total
Median Age
79
78
78
77.5
78
Age Range
64-93
58-95
55-94
38-92
38-95
41.3% male
58.7% female
31.0% male
69.0% female
38.4% male
61.6% female
36.4% male
63.6% female
37.1% male
62.9% female
44.6%
60.7%
69.6%
61.4%
60.2%
Gender
Live alone
The four properties are racially and ethnically diverse, as reflected in Table 2.3. All four
properties have a large immigrant population, with the dominant groups being Chinese and
Russian. Table 2.4 shows that the majority of residents completing the survey were born outside
of the United States and do not speak English as their first language.
Table 2.3: Resident Race and Ethnicity
Property 1
Property 2
Property 3
Property 4
Total
Hispanic
5.8%
3.9%
7.3%
21.0%
9.1%
White
58.2
41.7
13.8
35.9
34.3
Black or African American
1.1
6.0
2.2
1.2
2.5
Asian
37.8
50.0
79.0
52.3
57.8
Native Hawaiian or other
Pacific Islander
0
0
0
1.2
0.3
American Indian or Alaska
Native
0
0
2.2
1.2
1.0
2.2
1.2
.7
7.0
2.5
Other
Evaluation of the WellElder Program
10
Table 2.4: Resident Place of Birth and Language
Property 1
Property 2
Property 3
Property 4
Total
6.5%
26.2%
16.7%
6.9%
14.2%
6.6
26.2
19.0
9.2
15.5
Born in the U.S.
English is first language
Table 2.5 shows the proportion of residents in the four properties who report receiving MediCal
benefits.3 Across all the properties, over three-quarters of residents are able to access assistance
through the Medicaid program. The lower percentage of residents in Property 2 receiving
MediCal in comparison to the other properties may be due to the larger number of units in the
property that do not have attached rental subsidies resulting in some residents with higher
incomes that make them ineligible for MediCal.
Table 2.5: Resident Receiving MediCal
Property 1
Property 2
Property 3
Property 4
Total
82.7%
56.6%
84.9%
90.9%
79.7%
Receive MediCal
Health and Functioning
As shown in Table 2.6, between 62 and 85 percent of residents across the four properties
reported their health as fair or poor, while 15 to 38 percent said they were in good to excellent
health. According to the 2009 National Health Interview Survey, 23.9 percent of adults age 65
and over perceive their health as fair or poor. Among adults age 62 and older who receive both
Medicare and Medicaida population that may be comparable to the population in this
study52.8 percent rated their health as fair or poor (Center for Disease Control and Prevention,
2010).
Table 2.6: Self-Reported Health Status
Property 1
Property 2
Property 3
Property 4
Total
Excellent
0%
2.4%
2.9%
1.2%
1.8%
Very good
8.9
8.5
11.0
2.4
8.1
Good
8.9
26.8
24.1
11.8
18.5
Fair
56.7
48.8
44.5
52.9
50.0
Poor
25.6
13.4
17.5
31.8
21.6
The resident questionnaire also asked respondents to identify specific health conditions they
were currently experiencing. Table 2.7 shows the most common health conditions reported were
high blood pressure (67.2% of all residents), arthritis (66.8%) and heart problems (42.4%).
Several residents also reported memory-related disease (35.4%), diabetes (30.4%) and emotional,
nervous or psychiatric problems (27.8%).
According to the 2009 National Health Interview Survey, 51.0 percent of persons age 65 and
over report a doctor’s diagnosis of arthritis, 56.2 percent experience hypertension, 30.8 percent
3
MediCal is the name of the Medicaid program in Calinfornia.
Evaluation of the WellElder Program
11
suffer from all types of heart disease and 19.5 percent report diabetes (Center for Disease Control
and Prevention, 2010). Among persons age 65 and older who receive both Medicare and
Medicaid, the incident of these health conditions is higher: 58.3 percent report a doctor’s
diagnosis of arthritis, 69.1 percent experience hypertension, 36.4 percent suffer from all types of
heart disease and 29.9 percent report diabetes. These proportions are similar to those of the
survey respondents in the four housing properties.
Table 2.7: Self-Reported Health Conditions
Property 1
Property 2
Property 3
Property 4
Total
High blood pressure or
hypertension
68.1%
61.5%
67.4%
71.3%
67.2%
Arthritis or rheumatism
79. 1
67.9
57.1
67.4
66.8%
Heart problems
52.3
39.3
37.2
42.5
42.2%
Memory-related disease
44.8
24.4
29.8
45.2
35.4%
Diabetes or high blood sugar
36.3
19.3
31.3
33.3
30.4%
Emotional, nervous, or
psychiatric problems
40.9
23.2
17.8
33.7
27.8%
Cancer or a malignant tumor
11.5
6.0
9.2
11.8
9.6%
Chronic lung disease
6.8
6.2
4.6
14.3
7.6%
Several residents in the four properties experienced multiple chronic health problems, which
might indicate a significant need for services and supports. As shown in Table 2.8, between 44
and 70 percent of residents across the four properties reported having three or more of the
conditions noted in Table 2.7. In 2006, 54.2 percent of non-institutionalized Medicare
beneficiaries age 65 and older reported living with three or more chronic health conditions
(Cubanksi et al, 2010).
Table 2.8: Percent of Residents Reporting Multiple Chronic Health Conditions
Property 1
Property 2
Property 3
Property 4
Total
No Chronic conditions
3.3%
11.9%
12.2%
5.8%
8.7%
1+ Chronic conditions
96.7
88.1
87.8
94.2
91.3
2+ Chronic conditions
84.7
77.4
69.1
83.9
77.6
3+ Chronic conditions
70.6
46.4
44.6
60.9
54.3
Residents were asked if they were often troubled by pain and, if so, how bad the pain is most of
the time. Table 2.9 shows that 68 to 82 percent of respondents across the four properties reported
being in frequent pain. Of those, a large proportion is experiencing moderate to severe levels of
pain.
Evaluation of the WellElder Program
12
Table 2.9: Percent of Residents Troubled by Pain
Property 1
Property 2
Property 3
Property 4
Total
82.4%
67.9%
70.7%
78.2%
74.4%
Mild
9.3
15.0
33.7
7.3
17.7
Moderate
65.3
55.0
53.7
63.8
59.2
Severe
25.3
30.0
12.6
29.0
23.1
Often troubled with pain
Level of Pain
The self-administered survey also collected information on functional status to determine the
level and types of disability experienced by residents. This information is useful in estimating the
proportion of residents who might need assistance or services to help compensate for disability.
Table 2.10 presents the percentage of residents reporting functional limitations. Functional
limitations are classified into two categories—limitations in Activities of Daily Living (ADLs)
such as eating, bathing, dressing, getting in and out of bed or using the toilet and limitations in
Instrumental Activities of Daily Living (IADLs) such as preparing meals, managing money,
shopping, doing housework and using a telephone. Across the four properties, almost a quarter of
respondents reported no limitations in ADLs or IADLs, while one-fifth said they need assistance
with only IADLs and just over half reported needing assistance with one or more ADL.
Table 2.10: Percent of Residents Reporting ADLs and IADLs
Property 1
Property 2
Property 3
Property 4
Total
No ADL/IADL limitations
18.6%
35.7%
26.7%
16.5%
24.6%
IADL limitations only
17.4
15.5
21.5
28.2
20.8
1+ ADL limitations
64.0
48.8
51.9
55.3
54.6
According to the 2007 Medicare Current Beneficiary Survey, 13.8 percent of older adults aged
65 and above reported needing assistance with IADLs only and 24.5 percent reported needing
assistance with ADLs (Federal Interagency Forum on Aging Related Statistics, 2010). This
comparison suggests that the level of disability among the residents in the four housing
properties is higher than in the general population of older adults.
Table 2.11 details the types of ADLs and IADLs residents reported in the self-administered
surveys.
Evaluation of the WellElder Program
13
Table 2.11: Resident Reported Types of ADLs and IADLs
Property 1
Property 2
Property 3
Property 4
Total
36.1%
51.2%
48.5%
44.7%
45.5%
Bathing/Showering
51.8
34.2
35.9
25.9
36.9
Dressing
27.2
23.2
27.8
24.1
25.9
Transferring from bed/chair/car
30.0
22.9
31.8
26.6
28.3
Using the toilet
22.9
24.1
23.7
16.7
22.1
Incontinence
23.3
27.4
19.7
35.4
25.5
Eating
13.1
23.5
21.4
21.3
19.9
21.6%
39.8%
29.6%
17.6%
27.4%
Using the telephone
15.3
23.2
24.6
18.8
21.0
Shopping
64.7
38.6
38.0
55.4
47.9
Preparing meals
63.4
40.0
42.4
45.8
47.2
Housekeeping
68.7
45.0
54.2
60.7
56.9
Doing laundry
57.8
36.6
41.7
49.4
45.9
Traveling to places out of
walking distance
62.7
42.0
46.9
52.9
50.7
Taking medications
17.9
32.5
24.6
29.3
25.8
Managing money or finances
18.1
29.3
21.2
15.0
21.0
ADLs
No ADLS
IADLs
No IADLs
The self-administered survey asked residents if they had fallen down in the past 12 months and,
if so, how many times. Table 2.12 shows that about one-third of residents across the four
properties reported having a fall in the past year, with a median of 2 falls per resident reporting a
fall. According to the Centers for Disease Control and Prevention, an estimated three out of ten
persons age 65 and older experience a fall each year (CDC, 2006).
Table 2.12: Resident Reported Falls
Property 1
Property 2
Property 3
Property 4
Total
33.7%
32.5%
35.9%
37.4%
35.1%
Median # of falls
2.0
1.5
2
2
2
Range
1-8
1-6
1-10
1-5
1-10
Had a fall
Health Service Use
Residents were asked if they had gone to a hospital emergency room, been a patient in a hospital
overnight or had any outpatient surgeries in the past 12 months, and, if so, how many times.
Table 2.13 shows that between 27 and 40 percent of residents across the four properties reported
having a trip to the ER in the past year. A slightly smaller proportion, between 13 and 25
percent, reported having an overnight hospital stay. A number of residents across the four
properties, from 20 to 30 percent, said they had an outpatient surgery over the past year.
Evaluation of the WellElder Program
14
Table 2.13: Resident Reported Emergency Room Visits, Hospital Stays and Outpatient Surgeries
Emergency Room Visit
Property 1
Property 2
Property 3
Property 4
Total
39.8%
26.5%
29.8%
32.9%
31.7%
1
2
1
2
1
1-5
1-4
1-9
1-10
1-10
25.0%
13.4%
20.5%
20.0%
19.9%
2
2
1
1
1
1-7
1-5
1-37
1-7
1-37
30.1%
19.5%
30.4%
20.2%
25.7%
1
1
1.0
2
1
1-5
1-7
1-12
1-6
1-12
Median # of visits
Range
Hospital Stay
Median # of stays
Range
Outpatient Surgery
Median # of surgeries
Range
In 2006, 30 percent of beneficiaries in traditional fee-for-service Medicare reported at least one
visit to the ER. Among this same group, 21 percent reported at least one inpatient hospital stay,
but hospitalization rates varied by characteristics such as health status, age and income.
Hospitalization rates were higher among those in poor or fair health (38 percent and 30 percent,
respectively), among those ages 85 and older (33 percent), and among those with incomes less
than $20,000 (25 percent) (Cubanksi et al, 2010).
As Table 2.14 shows, respondents reported taking between zero and 21 different prescription
medications, with the median number of medications taken per person ranging between 4 and 7
across the four properties. According to the 2007-2008 National Health and Nutritional
Examination Survey, 37 percent of adults aged 60 and over used five or more prescription
medications (Gu, Dillon and Burt, 2010).
Table 2.14: Resident Reported Prescription Medications
Property 1
Property 2
Property 3
Property 4
Total
7
4
5
5
5
2-19
0-15
0-21
0-14
0-21
Median # of medications
Range
Support Network
The self-administered questionnaire asked residents about their informal support network and the
level of assistance they receive from this network. As shown in Table 2.15, an overwhelming
majority of respondents across the four properties reported having persons in the area who can
assist them when needed. Approximately 90 percent indicated they receive a call on a daily or
weekly basis from a family member, significant other or friend, while roughly 70 percent receive
a daily or weekly visit.
It should be noted that a large, but unknown, number of residents in the four properties
participate in the In Home Supportive Services (IHSS) program. IHSS is a Medicaid-funded
program in California that provides individuals with domestic and personal care assistance to
help them live safely in their homes. Services are provided by a personal aid and can range from
assistance with household chores to personal care such as dressing and bathing. Participants can
Evaluation of the WellElder Program
15
select a family member to serve as their aid, and some number of residents in the four properties
utilize a family member as their paid aid.
Table 2.15: Support from Family, Significant Others or Friends
Property 1
Property 2
Property 3
Property 4
Total
91.8%
84.8%
82.1%
92.7% (76)
87.1%
64.3%
46.1%
34.3%
60.2%
49.1%
Weekly
29.8
43.4
47.1
31.3
39.0
Monthly
3.5
5.3
6.7
2.4
4.8
Less than monthly
1.2
4.0
6.0
4.8
4.2
Never call
1.2
1.3
6.0
1.2
2.9
28.9%
13.7%
12.9%
33.3%
21.3%
Weekly
44.6
48.0
51.6
48.2
48.5
Monthly
10.8
15.1
16.1
6.2
12.5
Less than monthly
9.6
19.2
10.5
9.9
11.9
Never call
6.0
4.1
8.9
2.5
5.8
Persons in area who can assist
Call
Daily
Visit
Daily
Table 2.16 shows that respondents reported receiving a range in level of assistance. While
between six and 17 percent of respondents across the properties reported not needing any
assistance, between 23 and 46 percent reported receiving considerable assistance from their
family, significant others or friends.
Table 2.16: Reported Level of Assistance Provided by Family, Significant Others or Friends
Property 1
Property 2
Property 3
Property 4
Total
Do not provide assistance
6.1%
3.9%
10.9%
3.6%
6.7%
Limited assistance
28.1
35.9
28.9
18.1
27.8
Moderate assistance
18.3
20.5
25.0
26.5
22.9
Considerable assistance
39.0
23.1
23.4
45.8
31.8
I do not need assistance
8.5
16.7
11.7
6.0
10.8
Resident Incidents
Over the course of the eight-month data collection period, each of the four properties tracked
residents who experienced falls, 911 calls, emergency room visits, hospitalizations or nursing
home stays. Table 2.17 shows the percentage of residents in each property who experienced each
type of incident tracked as known to the property. It should be noted that a resident may
experience multiple incidents in a single occurrence. For example, a resident may call 911, be
taken to the emergency room and admitted to the hospital.
Evaluation of the WellElder Program
16
Table 2.17: Resident Incidents
Property 1
Property 2
Property 3
Property 4
Falls
2.4%
4.8%
2.1%
3.1%
911 Call
10.4
9.7
5.9
14.2
ER Visit
11.4
7.0
5.6
14.2
Hospital Stay
10.0
11.0
3.9
8.6
Nursing Home Stay
2.8
2.6
1.1
1.2
Resident Move Outs
Over the course of the eight-month data collection period, the four housing properties tracked the
number of residents moving out and where residents went after leaving the housing property. A
small number of residents moved out over the course of the year, with only eight to 14 residents
moving out across the four properties. As can be seen in Table 2.18, the most common reason
for move out in all but one property was due to the resident’s death. The next most common
destination after move out was with family. A smaller number of residents moved to a higher
level of care, such as assisted living or a nursing home. In light of the high level of frailty
evidenced in the resident population across the four properties, it would appear that a sizable
proportion of residents are able to remain in the housing properties, often until death, and avoid
moving out in search of higher levels of support.
Table 2.18: Resident Move Outs
Property 1
Property 2
Property 3
Property 4
Total
12
14
11
8
45
4.4%
6.4%
4.1%
5.1%
4.9%
Other senior housing
0
0
0
0
0
Other apartment
0
14.3% (2)
0
12.5% (1)
6.7% (3)
8.3% (1)
21.4% (3)
54.5% (6)
12.5% (1)
24.4% (11)
0
7.1% (1)
9.1% (1)
12.5% (1)
6.7% (3)
Nursing home
16.7% (2)
21.4% (3)
18.2% (2)
25.0% (2)
20.0% (9)
Death
75.0% (9)
35.7% (5)
9.0% (1)
37.5% (3)
40.0% (18)
0
0
9.0% (1)
0
2.2% (1)
Total move outs
% of resident population
Destination (% of total move outs)
Family
Assisted Living/RCFE
Other/unknown
Evaluation of the WellElder Program
17
Chapter 3 – WellElder Program Implementation
Program History
The WellElder program originated with residents at NCPHS and other senior housing properties
concerned that they did not want to move when their needs grew and they needed more
assistance. In response, a group of senior housing and service providers in the San Francisco area
convened a task force in 1991 to look at options for supporting residents to remain safely in their
home. After exploring various approaches, the group determined that services were available in
the community that could help keep most people in their homes; there just needed to be a better
mechanism to help residents access and utilize them. From this observation, the WellElder
program was developed.
The program’s goal was to help residents maintain their independence so that they could safely
remain in their apartments as long as possible. To accomplish this, the program paired a nurse
health educator with the service coordinator already operating in the housing properties. The
intent was for the health educator to enhance the service coordinator’s capacity by applying her
skills in assessing health-related needs, knowledge of health-related services and resources and
ability to communicate with the medical community. The belief was that through this tandem
approach the program staff could have a more comprehensive picture of a resident’s situation
and more effectively help address their spectrum of needs.
Although the program’s goal and team structure has remained the same, it has informally
evolved since its beginnings in 1996. The program’s path has been influenced by changing staff
and lessons learned and experience gained from responding to resident needs over time. Initially,
the program focused on helping residents connect to the services in the community that would
help them remain in their apartment. The first health educators were nurses contracted from a
PACE program, which gave them an appreciation for viewing residents comprehensively and a
knowledge of the community-based services system. The health educator’s role evolved with the
second set of nurses contracted from a home health agency who had more of a medical focus.
With this change, the health educators became more focused on activities like monitoring vital
signs. More recently the role has expanded to encompass a greater teaching component with an
emphasis on individual and group education around wellness and self-care management.
Program Elements
Overall Program Structure and Staff
The WellElder program is located within the NCPHS Community Services division and is
staffed by a service coordinator and health educator in each of the four properties. The four
service coordinators are supervised by the NCPHS Director of Community Services (Bethany
Center Senior Housing contracts with NCPHS for their service coordinator), but funded by each
housing property through the property’s operating budget. The service coordinator is a 32-40
hour week position in each property.
Evaluation of the WellElder Program
18
The health educator is hired by each housing property through a contract with the Institute on
Aging (IOA), a non-profit organization that provides a range of health and social services to
seniors in the San Francisco Bay area, and supervised by the IOA Older Adults Care
Management Division. The health educators are contracted to keep an arm’s distance from
anyone interpreting that the properties are providing care and supervision to residents, something
that would trigger licensing requirements for the housing provider in the state of California. One
nurse health educator splits time across Properties 1, 2 and 4, while two nurses share the health
educator role in Property 3. The health educator is funded through the property’s operating
budget and fundraising/grant sources. The number of hours the health educator is available in
each property is currently driven by available funding and staff from the IOA.
Table 3.1: Staffing Pattern
Property 1
Property 2
Property 3
Property 4
32 hrs/wk
40 hrs/wk
40 hrs/wk; split by two
individuals
40 hrs/wk
Directly employed
Directly employed
Directly employed
Contracted
Service Coordinator
Hours
Employment
mechanism
Funding Source
Operating budget
Operating budget
Operating budget
Operating budget
Health Educator
Hours
10 hrs/wk
10 hrs/wk
15 hrs/wk; split by two
individuals
4 hrs/wk
Employment
mechanism
Contracted
Contracted
Contracted
Contracted
Operating budget
Operating budget
Operating budget
Funding Source
Operating budget
Property 2 also has a psychologist who comes to the building once a week for two hours and is
contracted from private practice. She holds bi-weekly group sessions and conducts personal
visits on referrals from the service coordinator or health educator or at a resident’s request. She is
available to the WellElder team by phone or e-mail for advice, and also comes to the property if
a crisis necessitates it. While the goal is to have a mental health professional as a part of the team
in each building, the funding is currently not available.
Program Management and Oversight
There is no single line of authority for the WellElder program. As discussed above the service
coordinators are formally supervised by the NCPHS Community Services Director and the health
educators by the IOA. Program activities and parameters are defined by these two entities, as
well as the managers in each of the housing properties who can alter program components within
their building.
Quarterly meetings are held in each property with the service coordinator, health educator,
property manager, the NCPHS Director of Community Services a representative from the IOA.
The purpose is to talk about global issues/concerns, how to bring in more members and to let
property managers know about utilization of services and enrollment numbers. Only aggregate
numbers are provided and no confidential information is shared.
Evaluation of the WellElder Program
19
Participation in the Program
The WellElder staff refer to this program as a membership program that is open to all residents
in the housing property. There are no eligibility criteria or fees to participate. “Membership”
entitles residents to direct assistance from the health educator. The group education sessions and
activities provided through the program are available to all residents, whether they are members
of the program or not. All residents may also access the service coordinator.
New residents are generally informed of the program through a printed brochure and/or direct
introduction to the service coordinator and health educator. Property management may bring a
new resident to see the WellElder staff or alert the staff that a new resident has moved in so that
they may visit them. While many residents choose to join the program when they move in, some
join at a later date or may choose to never join. WellElder staff attempts to continually inform
residents about the program through presentations at resident events or through direct resident
contact. Table 3.2 shows the proportion of residents WellElder members and non-members in
each property at the beginning of the study period.
Table 3.2: WellElder Program Membership
Property 1
Property 2
Property 3
Property 4
Members
202 (70.0%)
182 (79.8%)
155 (54.6%)
129 (79.6%)
Non-members
87 (30.0%)
46 (20.2%)
129 (45.4%)
33 (20.4%)
Residents who join the program at a later date do so for different reasons. According to
WellElder staff, an incident or crisis may lead residents to see that they may benefit from some
type of assistance. Sometimes they see that a neighbor or friend has had a positive interaction
with the WellElder staff and they decide the program may be able to help them. Residents who
participate in the program will also sometimes bring their neighbors down to the service
coordinator or health educator when they think they need help.
In the self-administered questionnaire, residents who are not members of the WellElder program
were asked why they had not joined. Table 3.2 aggregates the responses for non-members across
the four properties. The most common reason for not joining is lack of awareness of the program.
Several non-members also believe they get their health-care needs met by their physicians or are
able to manage their needs on their own. Few non-members were concerned about the property
management becoming aware of their health or functional status.
Evaluation of the WellElder Program
20
Table 3.3: Non-Member Reasons for Not Joining WellElder Program*
I am not aware of the WellElder program and need more information.
59.5%
I get all my health care needs met by my doctor and other health care providers.
38.0
I am aware of all the resources and services available to me in the community.
25.3
I am independent and do not need assistance from anyone.
22.8
I am knowledgeable about my health care situation and managing all my health care needs.
22.8
My family members help me with everything and I don’t need help from the building staff.
15.2
I do not want the housing property staff to know about my private life.
11.4
I am not sure the building management will let me continue to live here if they think I have become sick
or disabled.
7.6
*Respondents were allowed to choose multiple answers.
The self-administered questionnaire also asked non-members if they might join the WellElder
program in the future. Table 3.4 shows that the majority of respondents either will or will
consider joining the program, if their needs change.
Table 3.4: Potential of Joining Program in Future
No
9.8%
Possibly, if my needs change
40.2
Yes, when my needs change and I need assistance
50.0
To join the program, residents complete an enrollment form that asks for contact and health
insurance information. The form also secures the resident’s consent for the health educator to
access appropriate information to help in assessing and responding to the resident’s needs.
Residents who utilize the service coordinator, whether WellElder members or not, also complete
a separate consent to release/request information form and a confidentiality agreement.
There is no formal assessment process upon joining the program. NCPHS service coordinators
utilize the assessment form contained in AASC online, a resident data management tool, which
asks about physical functioning, emotional status, community supports, transportation needs and
mental functioning. Service coordinators may informally go through this assessment with
residents when they first meet or they may gather the information over time. The health educator
does not do a formal assessment, but informally gathers information through a conversation.
How Residents are Assisted
Assistance is primarily provided through one-on-one contacts. No appointments are required and
residents may drop by the service coordinator or health educator office anytime during their
working hours (generally Monday-Friday, 8-5). Contact is primarily initiated by residents;
however, WellElder staff also reach out to residents. Staff may follow-up with a resident they are
assisting or may check on a resident they have not seen in a while, particularly if they know the
resident may have ongoing issues. WellElder staff also outreach to residents who they or other
property staff perceive may be having a problem. Maintenance staff, for example, frequently
identifies concerns about residents. “I’ve had maintenance come many times and say ‘come with
Evaluation of the WellElder Program
21
me to see someone, I think they’re sick or they won’t call their doctor,” says one service
coordinator.
Meetings generally occur in the service coordinator or health educator’s office, but might also
take place over the phone or in a resident’s apartment as warranted. WellElder staff may also
visit residents in the hospital or nursing facility. The service coordinator and health educator
generally meet individually with residents, although they will also see a resident jointly when
called for. This happens more frequently in the properties where the service coordinator and
health educator are co-located. In Properties 1, 2 and 4, the service coordinator and health
educator are located in adjoining or common spaces. In Property 3, each office is on a separate
floor in opposite ends of the building. “Someone might be here and I’ll send them over to [the
service coordinator] and vice versa; that’s the beauty of being co-located here,” says the health
educator, “I’ll pull up a chair and we’ll have an impromptu case conference. I’ll hear a resident
talking to [the service coordinator] and I’ll just go over and say I know that answer.” This
interactive dialogue is less frequent in the property where the health educator and service
coordinator are not located near each other. They will, however, refer residents to each other and
may occasionally walk residents to see the other.
The service coordinators and health educators informally review residents with each other;
although this tends to happen more frequently in the properties where the team is located
together. “We check in with each other,” says one health educator, “Since I’m not here every day
we go over our lists with each other. [The service coordinator] may have left me messages
asking me to check on people or things to follow-up on. It’s fairly informal, it just sort of
happens.” In the property where the service coordinator and health educator are located on
separate floors, communication about residents tends more to be through e-mail and phone.
In addition to one-on-one visits, the WellElder team also conducts and/or organizes group
education session by outside entities. Education sessions are handled slightly differently between
the San Francisco and San Jose properties. The San Francisco properties have created “Wellness
for You,” a program that focus on the mind, body, spirit connection and under which most group
education and discussion activities are organized. The session topics are determined by the health
educator and the service coordinator from Property 1, who together present many of the sessions
together at the three San Francisco properties. Other sessions are presented by outside
organizations or individuals. Sessions are translated into Chinese at each property. They are not
currently translated into Russian, the other dominant ethnic group in the properties, because few
Russian-speaking residents attend the group sessions. WellElder staff believes this is partially
because many are often out of the building attending programs, classes or providing childcare for
their extended families. The San Jose property also provides group education sessions. The
sessions are provided by the health educators and by community organizations. Ideas for the
topic sessions are generated primarily by the health educators, but they also get input from
property management, the NCPHS Director of Community Services and residents. A list of the
group education sessions provided during the study period can be found in Appendix A.
The health educator in the San Francisco properties also produces a biannual newsletter, which is
distributed to residents in all four properties. The two-page newsletter addresses topics such as
Evaluation of the WellElder Program
22
preventing dehydration, arthritis, keeping an active brain, improving balance, and so on. The
newsletters are not currently translated into other languages.
Table 3.5 reports the number of visits WellElder members made to either the service coordinator
or health educator for WellElder-related services over the study’s eight-month data collection
period.4 The differences in the number of visits across the properties may be due to a variety of
factors, including the size of the property, the number of WellElder members, the amount of time
of time the WellElder staff (particularly the health educators) are at the property, the style of the
staff members in approaching and working with the members, and the needs of the members.
Table 3.5: Number of Member Visits to WellElder Staff
Property 1
Property 2
Property 3
Property 4
Total
Service Coordinator
399
936
381
714
2430
Health Educator
254
295
366
314
1229
Total
653
1231
820
1028
3659
Table 3.6 shows the proportion of WellElder members who visited the service coordinator, the
health educator, either staff member or both staff members at least once during the eight-month
study period for WellElder-related services. Across the four properties between 44.6 and 82.9
percent of WellElder members saw the service coordinator and from 32.6 to 46.7 percent saw the
health educator. A higher percentage of members visited the service coordinator, but it must be
kept in mind that the health educator is only in each property between 4 and 15 hours each week
(see Table 3.1). A smaller, but still sizable, portion of members visited both the service
coordinator and health educator. It is not clear whether these members were seeing each staff
member for the same issue, but this proportion may reflect members benefitting from the team
approach of the service coordinator and health educator to help meet their needs. In Property 2,
which shows the highest percentage of members visiting both the service coordinator and health
educator, the health educator reports that the service coordinator frequently refers residents to
her, sometimes walking members to her or taking the health educator out to see a member.
Table 3.6: Percent of Participants with At Least One Visit to WellElder Staff
Property 1
Property 2
Property 3
Property 4
Total
WellElder Members
202
182
155
129
668
Service Coordinator
44.6%
80.8
50.3
82.9
63.2
Health Educator
45.5%
46.7
46.4
32.6
43.6
Either (SC or HE)
65.8%
86.3
72.3
85.3
76.6
Both (SC and HE)
24.3%
41.2
24.5
30.2
30.1
Table 3.7 details the average number of visits WellElder members had to the service coordinator,
health educator or one or the other over the eight-month study period for WellElder-related
activities. In three of the four properties, residents have a higher average number of visits with
4
Only service coordinator activities considered a Well-Elder related service were tracked as a part of this study.
WellElder services are those that have a health or wellness-related implication (See Table 3.9). All service
coordinator activities were not included. For example, if a service coordinator assisted a WellElder member with
obtaining an energy rebate for low-income seniors, that activity was not tracked.
Evaluation of the WellElder Program
23
the service coordinator than the health educator. Again, the smaller number of hours the health
educator is available in each property must be considered. In Property 4, the health educator has
a higher average number of visits than the service coordinator and in comparison to the health
educators in the other properties. As will be discussed later, this property has a number of
members who visit the health educator regularly for blood pressure checks.
Table 3.7: Average Number of Visits to WellElder Staff per Member
Property 1
Property 2
Property 3
Property 4
Total
Service Coordinator
4.4 (5.9)
6.4 (6.2)
4.9 (6.6)
6.7 (5.5)
5.8 (6.1)
Health Educator
2.8 (4.5)
3.5 (5.7)
5.1 (8.1)
7.5 (8.7)
4.2 (6.7)
Either (SC or HE)
4.9 (7.5)
7.9 (9.0)
6.7 (8.9)
9.4 (10.3)
7.2 (9.0)
Table 3.8 attempts to understand the intensity with which WellElder members visit the service
coordinator and health educator by looking at the percentage of residents who have more than
five visits with the staff members over the eight-month study period. It is unknown whether
repeat visits are for related or separate issues, but a higher frequency of visits may reflect
members with a higher level of need. In Properties 3 and 4, the health educator has a higher
proportion of members with repeat visits. As will be seen below, each of these properties has a
number of members who see the health educator for regular blood pressure checks.
Table 3.8: Percent of Members with At Least Five Visits to WellElder Staff
Service Coordinator
Property 1
Property 2
Property 3
Property 4
Total
13.4%
37.4%
14.8%
46.5%
26.6%
Health Educator
5.9
7.1
13.5
13.2
9.4
Either (SC or HE)
16.3
44.0
27.7
50.4
33.1
Both (SC and HE)
4.4
6.0
3.2
10.9
5.8
Services Provided
The WellElder program assists residents in a number of areas. While the service coordinator and
health educator help across some common areas, they primarily assist in matters that utilize their
respective professional training and skill sets. Service coordinators are adept at navigating the
service network and helping residents identify resources that can help meet their needs and
enhance their quality of life. With their medical training, health educators assess and provide
guidance on a resident’s health situation.
All assistance is provided only with the resident’s consent. Residents are also free to choose what
services and activities they wish to engage in. Although the service coordinator or health
educator may try to encourage them to utilize resources they believe may benefit them, the
decision is ultimately the resident’s.
Service Coordinator Assistance
Assistance provided by the service coordinator includes:
•
Assessment. Service coordinators evaluate residents to understand their issues and needs
and identify potential services and resources that may assist them.
Evaluation of the WellElder Program
24
•
Identifying, accessing and maintaining benefits. Service coordinators help residents find
services that can help meet their health-related needs, such as home care assistance,
meals programs or transportation programs, and benefits such as Medicaid, food stamps
or drug discount programs. As many service and benefit programs have detailed
applications, often requiring extensive documentation, service coordinators often assist
with the application process. The processes can be particularly difficult for residents who
have limited literacy, do not speak English as their primary language or have memory
issues. Service coordinators also have an understanding of the type of information and
level of detail that can help make an application successful, and can guide residents on
maximizing their chances of receiving a service or benefit. They can also assist with
gathering the required forms of documentation, which may range from copies of birth
certificates to signatures from doctors. When applications are denied, service
coordinators can help residents understand why and can help advocate for residents if
they believe an application was wrongly denied. Service coordinators also assist residents
with recertifications to help ensure residents maintain continuity of their benefits. Many
times residents do not realize they need to do this and may misunderstand or ignore
reminder letters.
•
Bill reconciliation. Residents often bring their doctor, hospital or other medical bills to
service coordinators not understanding why they are being charged. Often a problem is
due to inaccurate or incomplete insurance information. Resolving such issues can require
many phone calls and following up with written documentation. For many residents, it
can be difficult to work through phone systems, identify the correct person to talk to and
understand and follow-through on the necessary steps to correct billing problems. This
can be particularly daunting for non-English speakers or persons with diminished
memories.
•
Supportive counseling. Service coordinators motivate and encourage residents in their
ability to manage their health-related needs and to live a full and quality life, regardless
of what their health and functional status may be. Many residents have no one to talk to
or are reluctant to tell their family members about their health problems, and service
coordinators can be a sounding board for them. For residents with fear or doubt about
utilizing services, service coordinators can help them see how the services may benefit
them and encourage follow through. Because service coordinators have relationships with
residents, they often know their values and what motivates them, information they can
use to encourage a resident to accept services.
•
Outreach. While service coordinators are most often reacting to residents who come to
them, they also reach out to residents they perceive may be having problems and/or who
they think may benefit from or be interested in services or activities they may not be
aware of. In addition to their own observations, property management staff and other
residents will also alert service coordinators when they have concerns about a resident.
Some service coordinators accompany the property manager during an annual inspection
of units. This allows them to identify concerns, such as cords or rugs that may pose a fall
risk or poor hygiene that may be a sign of a medical problem.
Evaluation of the WellElder Program
25
•
Follow-up/monitoring. Service coordinators attempt to monitor and follow-up on resident
issues and needs. This can range from tracking a resident’s application or recertification
for services or benefits, to their participation in a service or program, to keeping an eye
on them after a health-related incident or general decline in health or functional status.
Some residents participate in community programs where they have a case manager or
social worker. In these instances, service coordinators may update the program staff with
any pertinent information, since the case manager or social worker may not see the
resident on a frequent basis.
•
Discharge planning. Service coordinators attempt to participate in the discharge planning
process when a resident has a hospital or rehabilitation facility stay. The goal is to help
ensure the resident is not being discharged too early, that the discharge planner is fully
aware of the resident’s living environment and support mechanisms (i.e. that they do not
live in an assisted living facility) and that all necessary services and supports are put in
place to enable the resident to have a safe return home. Service coordinators may also
talk with family members to educate them on what they should discuss with discharge
planners and ensure is in place.
•
Medical coordination. Service coordinator can assist residents with scheduling
appointments with physicians and arranging medical for medical tests. Residents may
have difficulty communicating with staff, working through automated phone systems, or
understanding what entity to schedule tests with.
•
Legal forms. Service coordinators can educate residents about documents such as
advanced health care directives and help with their preparation.
•
Grief and loss. Service coordinators provide counseling to help residents deal with the
death of a family member, friend or neighbor.
•
Emergency health information sheet. In Properties 1, 2 and 4, the service coordinator and
health educator help residents prepare and annually update an information sheet that lists
health information such as their doctor, insurance information and medications. In the
event of an emergency, this sheet can be given to paramedics by the resident or a
WellElder or property staff member. The residents are also given the medication list to
carry with them.
Table 3.9 shows the frequency of types of assistance provided by the service coordinator to
WellElder members in each housing property over the course of the eight-month data collection
period. The rate of services provided varied across the four properties, possibly reflecting
differences in the number of members, member need and service coordinator style. Nonetheless,
the most common areas of assistance across the service coordinators generally were assessment,
outreach, supportive counseling, securing benefits and follow-up/monitoring.
Evaluation of the WellElder Program
26
Table 3.9: Frequency of Services Provided by Service Coordinator
Property 1
Property 2
Property 3
Property 4
Assessment
158
196
5
73
Outreach
37
257
14
104
Socialization
14
54
0
86
Supportive Counseling
60
204
33
179
Securing Benefits
96
157
82
341
Bill Reconciliation
35
14
24
87
Education
4
1
5
22
Legal Forms
13
13
3
4
Emergency/Health Info Sheet
7
5
7
12
Grief and Loss
14
13
1
5
Medical Coordination
42
32
58
38
Hospital Discharge Coordination
21
26
13
2
Hospital Visit
3
1
3
2
Follow-up/Monitoring (includes post
hospital/rehab)
85
342
174
276
Nurse Health Educator Assistance
Assistance provided by the health educator includes:
•
Monitor vital signs. Health educators help residents monitor vital signs such as blood
pressure, heart rate and weight. Some residents come regularly to have their blood
pressure or other vitals checked, while others only come when they believe there might
be a problem.
•
Health education. Health educators instruct residents on a variety of health-related topics,
including diseases, medication, exercise, nutrition and compliance. They can help
residents understand their diseases and the best ways to manage their conditions and care
for themselves. Health educators can interpret lab results to help residents understand
what the results reveal about their condition and offer advice about follow-up. They can
help residents understand what their medications are for, the proper ways to take them
and potential side effects to be aware of. While the health educators do not conduct
invasive procedures such as wound management, they can teach residents how to
properly maintain a wound and signs of infection.
•
Medical coordination. Health educators help residents coordinate their medical care in a
variety of ways. They can assist residents with calling their doctor’s office to set up
appointments or to answer questions. For some residents it can be difficult to work
through the phone system and/or to stay on hold for extended periods. Health educators
may also help residents prepare for doctor visits by helping them create a list of questions
to ask and/or information to provide their physician. They can also identify potential
problems a resident may not see. For example, one resident with uncontrolled blood
Evaluation of the WellElder Program
27
pressure was told to stop all medications and then come in for an appointment to
determine a new medication regiment. The resident was not able to get an appointment
for over three weeks. Recognizing this could be dangerous, the health educator worked
with the physician’s office to find a better solution. Health educators can work with
pharmacies to set up mechanisms for residents needing assistance managing their
medication. Health educators will also conference with a resident’s care providers to
ensure they are fully aware of a resident’s situation and their needs are getting met. For
example, if a resident’s home health course following a hospital stay is ending, the health
educator may talk with the home health nurse if they believe the resident is not yet stable
enough to be on their own.
•
Assessment. Health educators can assess residents’ health-related concerns, help them
identify what might be possible problems and solutions and recommend whether they
should follow-up with their physicians. In extreme circumstances, the health educator
may call the resident’s physician or 911. They may also contact the resident’s family
member. Some residents are reluctant to follow-up and the health educator assesses
whether the situation presents an immediate emergency.
•
Discharge coordination. When the timing and circumstances permit, the health educator
in the San Francisco properties may visit residents in the hospital and/or rehabilitation
facility to engage in the discharge planning process. Because of the limited time at each
property, the health educator will more likely visit the resident after they have returned
home to make sure the resident has everything in place they need to successfully care for
themselves.
•
Supportive counseling. Much like the service coordinator, the health educator encourages
residents in their ability to manage their health-related needs and live a full and quality
life.
For members who may have difficulty getting to the health educator’s office, the health educator
will provide assistance over the telephone or visit the resident in their apartment.
The nurses do not engage in any invasive procedures such as giving injections, performing blood
glucose checks (although they will guide a resident through doing it themselves), and dressing
wounds. Nor do they monitor residents’ medications. These limitations are in place for a couple
reasons, according to WellElder and NCPHS staff. Because the health educators are only at the
properties for a limited amount of time, they are concerned they would not be available to
follow-up should additional action be needed or in the case of a complication. In addition, the
State of California prohibits housing properties for the elderly or disabled to provide care and
supervision without being licensed as a Residential Care Facility for the Elderly. The housing
property may “coordinate or help residents gain access to the supportive services either directly
or through a service coordinator." The allowable scope of practice for RNs and LVNs must also
be considered so that the health educator’s nursing license is not put in jeopardy.
Table 3.10 shows the frequency of types of assistance provided by the health educator to
WellElder members in each housing property over the course of the eight-month data collection
Evaluation of the WellElder Program
28
period. The rate of services provided varied across the four properties, possibly reflecting
differences in the number of members, member need and the amount of time the health educator
is available at each property.
The most common service provided is vital sign checks, primarily blood pressure. In some
instances members receive other types of assistance, often related education, while having their
blood pressure measured and in others they only have a blood pressure check (see row “Vital
Sign Alone” in Table 3.10). Properties 3 and 4 have several members who come to the health
educators regularly just to have their blood pressure monitored. In Property 4, this is the
dominate service and limited assistance is provided in other areas. The health educator believes
she is hampered by the small amount of time she is in the property each week (4 hours) and the
number of residents who come weekly to check their blood pressure, giving her limited time to
reach out to residents and try work with them in other areas. While this same health educator also
conducts a number of blood pressure checks in Properties 1 and 2, she is also often providing
concurrent services such as education.
Health educators believe blood pressure checks are a gateway to build rapport with residents and
establish a relationship, find out more about their health issues and provide education. While
checking their blood pressure, health educators might offer residents advice about their
medication, diet or exercise regimens. Residents might also talk about other health-related issues
while in the office. “Sometimes we’re troubleshooting by little things they are mentioning to us,”
says one health educator. Residents also often take a log of their blood pressure readings to their
doctor. The health educators note that individuals often get stressed during doctor’s visits and
doctors will prescribe medications based on these abnormal readings. The logs allow doctors to
see an accurate history of the resident’s blood pressure levels. For some residents, the WellElder
staff believes, the regular blood pressure monitoring simply reassures them that everything is ok.
In comparison to the frequency of vital sign checks, all other areas of service are much lower.
Health-related education is one of the next most common areas. [Table 3.10 does not include
group education participants.] Health educators also provide residents with supportive
counseling, encouraging them in their ability to manage their health situation.
Health educators in three out of the four properties visit members in the hospital or rehab
facilities. (The health educator in Property 3 is prohibited from these activities per the instruction
of the property manager). These visits are limited, however, by the timing of the member’s
hospital/rehab stay and the days she is at the property. Although health educators visit members
after they return from the hospital on a slightly more frequent basis, this follow-up is more often
conducted by the service coordinators as they are on-site at the property on a regular basis.
Service coordinators will often exchange information with the health educators about the
returning resident and get them involved if they have concerns about the resident’s situation.
The health educator’s role in coordinating with health-related providers is minimal across the
four properties. The health educators may not be at the property when the resident needs
assistance with coordinating medical care or with medical specialists. Although health educators
sometimes prep residents for their doctor appointments (e.g., getting their medications in order,
helping them to identify key questions), they are often not aware when members have doctor’s
Evaluation of the WellElder Program
29
appointments or may not be at the property around the time a member has an appointment.
Members may also not recognize that the health educator can assist them in this area. Help with
medical coordination is highest in Property 2, which may reflect the service coordinator’s greater
tendency to engage the health educator.
Table 3.10: Frequency of Services Provided by Health Educator
Property 1
Property 2
Property 3
Property 4
Service Coordinator Case Conference
14
32
8
3
Follow-up/Monitoring
29
24
8
18
Emergency/Health Info Sheet
59
39
0
25
Vital Signs
121
170
349
252
Vital Signs Only*
49
98
222
244
Use of Equipment
37
37
4
1
Disease Education
18
22
50
16
Medication Education
35
36
65
12
Compliance Education
7
9
6
6
Exercise Education
0
0
13
1
Nutrition Education
8
2
16
9
Supportive Counseling
19
21
67
2
Call 911
5
3
0
0
Hospital or Rehab Visit
12
5
0
0
Follow Up Post Hospital Stay
10
10
4
5
Prep for MD Appointments
1
1
8
0
Call MD
4
9
5
1
Medical Coordination
7
23
5
1
Adult Day Service/PACE Coordination
0
7
3
1
Home Health Care Coordination
3
7
0
1
Mental Health Services Coordination
0
14
0
0
Medical Specialists
4
1
1
1
Paratransit
0
1
0
0
* This category reflects a visit where the member only had their vital signs checked (generally blood pressure) and received no
other type of assistance.
During a visit with the WellElder staff, members may receive assistance in multiple areas. For
example, a member visiting the service coordinator may receive an assessment and assistance
with accessing a drug discount program or a member seeing the health educator may receive a
blood pressure check and nutritional education.
See Exhibit 1 at the end of the chapter for examples of residents who were assisted by the
WellElder program during the study period.
Evaluation of the WellElder Program
30
Coordination Between the Service Coordinator and Health Educator
There is no formal process for case conferences where the health educator and service
coordinator discuss a resident with more complex needs. This activity occurs on an ad hoc basis
and most frequently in Property 2, which may be a reflection of the service coordinator’s
tendency to engage the health educator more frequently with members. Case conferences are
minimal in Property 4, which likely reflects the health educator’s limited time at the property.
Conferences are also infrequent in Property 3, which may be influenced by the distance between
the service coordinator and health educator offices. (See Table 3.10.)
Integration of Property Management
Each housing property is overseen by a management team—which includes a manager and
administrative, maintenance and security staff—that is responsible for the building’s operations
(lease-related activities, building upkeep and maintaining safety and security). Through their
roles, property management staff frequently interacts with residents and may observe possible
concerns with residents. For example, maintenance staff may see signs of a struggling resident
when in their apartment making repairs or security staff may see a resident displaying strange
behavior in the middle of the night. When doing annual apartment checks property managers
might come across a unit that is excessively dirty, which could indicate a resident is declining in
their ability to care for themselves. The property management staff, therefore, has the potential to
serve as an important partner with the WellElder team.
The property managers of the four properties have different philosophies concerning interactions
with the WellElder team. One property manager generally takes a “hands off” approach,
informing the service coordinator about resident issues and then stepping out of the picture if
there is not a tenancy issue to maintain a division between the service coordinator and property
management. “I won’t know how they work with them because of confidentiality,” says the
property manager. Another alerts the service coordinator about resident issues, but may stay
peripherally involved with the resident’s permission. “The way I look at it, we’re a team of
support for the residents,” says this property manager. A third property manager is more hands
on with resident issues, sometimes dealing with them directly rather than turning them over to
the WellElder team.
Property staff generally alert the service coordinators to resident situations that may potentially
have physical or mental health issue behind them. One property manager promotes direct
interaction between all staff. “It’s critical for all of us to share what we see and hear. Building
staff is in places we don’t go to,” says one manager, “They have direct connection with them.
We have monthly staff meetings and most everyone has e-mail where they can communicate
what they see and hear. One example is we have fire drills and it’s important for us to know
about the people who have difficulties. The service coordinator and health educator may have
ideas on the best ways for us to manage or organize assisting them out of the building.”
Another property manager asks property staff to bring their concerns or observations about
residents to them. “We ask maintenance and security to come to management with any resident
issues and then we carry it to the service coordinator,” says this manager, “We do that because
we have to look in two directions, the property management side and the resident side. . .I need
Evaluation of the WellElder Program
31
to be aware of what’s going on in the building because of potential legal aspects and then I’ll go
talk to the service coordinator.”
The property manager who attempts to maintain a line between property management and the
service coordinator also acknowledges there are times when it is valuable for the two entities to
work together. For example, a resident may be declining but refuse to work with the service
coordinator. The property manager can tell them it is a requirement of their lease for them to
maintain their apartment in good condition to stay in the building and they should work with the
service coordinator. “It’s kind of a good cop/bad cop role,” says the property manager, “the
intention is not to move them out, but it’s a strategy to get the resident to seek help.”
There is a potential for tension to develop between the property managers and the WellElder
staff because of their differing responsibilities. The property manager is accountable for
upholding all lease-related requirements and maintaining the upkeep and safety of the building,
while the service coordinator and health educator are advocates and confidants for residents. In
situations where lease violations or potential liabilities to the building exist, conflicts may arise
in the extent to which information is shared or the perspective on how problems should be
resolved. One property manager noted tension was rare with the WellElder staff because they
have become very comfortable with each other’s roles and how much information the property
manager needs to know. “They know my areas where I need to be informed and I know theirs,”
the manager says. Another manager notes, “We constantly have conversations about how to best
utilize each other. If you keep communication open, it can work. Sometimes someone will say
I’m not supposed to share that, but learn down the road that they could have shared and resolved
the problem earlier. Otherwise, there’s no conflict because we’re here as a team and we’re
focused on the residents.”
Evaluation of the WellElder Program
32
Exhibit 1: Examples of Residents Assisted through the WellElder Program
Resident A – Resident A has major memory problems. She takes Coumadin, a blood thinner that
requires regular monitoring, and has to be reminded to of her lab work and doctor appointments.
The doctor’s office alerts the health educator of new appointments so she can help the resident
keep track of them. The health educator worked with her pharmacy to get her prescriptions
packaged to help her take the right medications at the right time. The resident developed a
problem with her hand and the health educator was concerned her doctor was not addressing it.
Because she uses a walker, it is important she have good use of her had. The service coordinator
also became aware of a stack of unpaid bills. Given her multiple needs, the WellElder team
believed the resident would benefit from the PACE program. She was reluctant to join, but the
educator and service coordinator were able to convince her of the benefits. She will be followed
regularly by a physician, will get in home assistance and a social worker will be able to assist her
with managing her affairs.
Resident B – Resident B was admitted to the hospital after a syncopal episode and continued to
struggle with weakness after returning home. The resident also suffers with glaucoma. Although
the reason for his syncopal episode was unknown, he may have taken his blood pressure
medicine incorrectly due to his impaired vision. The service coordinator helped him secure an
aid through the IHSS program to assist with his personal and home care needs that are difficult
for him to perform. The aid can also help prevent some of the dangers associated with his
declining vision, for example, sorting his medications into a pill box. When his aid was in an
accident and unable to work, the service coordinator put in a request for an emergency substitute
so he would not go without assistance. The resident had glaucoma surgery and was refusing to
do the suggested follow-up rehab. The service coordinator was able to convince him to follow
through.
Resident C – Resident C received several new prescriptions following a hospital stay without
any explanation. The health educator explained what the medications were for and how they
should be taken and then checked in periodically with the resident to make sure everything was
going ok.
Resident D – Resident D had an incident that resulted in him being hospitalized for a psych
evaluation and being served an eviction notice. The WellElder staff interacted with the doctor to
help them figure out what might be happening with the resident. The service coordinator also
connected the resident with a legal advocate and APS to assist him with dealing with the
potential eviction. Around the same time, the resident was scheduled to have surgery, but due to
a mix-up with his insurance card the surgeon was unwilling to perform the surgery for fear he
would not get reimbursed. The service coordinator assisted him with correcting the insurance
problem and finding a doctor who would perform the surgery. The surgery was scheduled as a
day surgery. Because the resident is in his late 80s and a weakened state, the service coordinator
was concerned about him returning to his apartment immediately and convinced the surgeon’s
office to keep him in the hospital. The service coordinator then connected with the discharge
planner to help ensure they put the necessary supports in place. After returning from the hospital,
the service coordinator suggested that he could benefit from the multiple supports the PACE
Evaluation of the WellElder Program
33
program could provide. Initially unwilling, the service coordinator was eventually able to
convince him of the program’s benefits and his application is pending.
Resident E – Resident E was almost evicted due to his hoarding behavior. The service
coordinate assisted him with obtaining a mental health advocate who helped him work out a
solution with property management allowing him to stay in his apartment. The service
coordinator identified a volunteer group to help clean his apartment. He has health problems,
poor hygiene and difficulty taking his medications properly and keeping medical appointments.
He decided to join the PACE program after attending a presentation at the property. The service
coordinator and PACE social worker collaborate to help him manage his hoarding behavior.
Residents F – Residents F are a husband and wife who regularly see the health educator to get
their blood pressure checked. The husband is now developing Alzheimer’s and Parkinson’s and
asks the health educator to help him communicate with his doctors. She also provides him with
education on his health issues. The wife is a diabetic who has difficulties using her glucose
monitoring machine and the health educator helps her with the machine.
Resident G – When the health educator found Resident G’s blood pressure to be high, she told
the health educator that her doctor said it is just like that. The health educator told her she would
still recommend her doctor check it out. Resident G visited her doctor and they discovered she
was retaining fluid, which was causing the high blood pressure. She started on a diuretic and the
problem resolved. Later Resident G had foot surgery and the health educator checked on her to
see if everything was healing properly. The health educator talked with her about good follow-up
care and what to do for pain control.
Resident H – Resident H has low iron problems and must have her blood checked weekly. Due
to her weakened state, it became difficult for her to ride the regular bus to get this done and the
service coordinator helped her get established with Paratransit. Her weak state makes it difficult
for her to take of many things and the service coordinator is also helping her apply for an aid
through the IHSS program. Resident H also cares for her husband, who has dementia.
Resident I – Resident I has health problems and is also caring for her husband, who is losing his
eyesight. The service coordinator assisted them with getting an aid through the IHSS program.
The service coordinator and health educator repeatedly encouraged Resident I to talk with her
doctor about her health problems, but she said the doctor would not do anything to find out what
may be the cause. They talked with her about changing doctors, but she would not do it out of
concern of offending the doctor. The service coordinator and health educator were eventually
able to convince her to switch to a new doctor, who ran tests and identified the problems.
Evaluation of the WellElder Program
34
Chapter 4 – Study Findings
Program Benefits
The study team interviewed the WellElder staff and property managers in each of the four
properties about their perception of how the WellElder program benefits residents who
participate in the program, the property and other entities such as family members and
community service providers. Residents participating in the program were also asked how they
believe the program benefits them in both the self-administered survey and focus groups.
WellElder Staff Perceptions of Resident Benefits
WellElder staff believes the collaboration between the health educator and the service
coordinator benefits residents in multiple ways. While service coordinators can often become
adept at assisting residents in a range of health-related areas, WellElder staff says there are
advantages the health educator brings to the team by virtue of their education and training. Their
medical background, the service coordinators say, provides a knowledge and insight that a
service coordinator’s training does not afford. The health educator can:
• Assess residents to help identify potential health-related problems and possible solutions.
• Notice subtle changes in condition that may signal a health problem to be addressed with a
physician.
• Have a greater understanding of what having a certain disease or condition may indicate
about a resident’s immediate and long-term needs.
• Have a better understanding of a resident’s medical situation when the person comes home
from the hospital, including potential complications and what to monitor for.
• Review a resident’s medications and identify potential unnecessary, duplicative or
problematic medications about which resident should confer with their doctor, and educate
the residents about potential side effects.
• Explain to residents why their doctor may be ordering certain diagnostic tests or what the
results of those tests might mean.
• Educate residents about health and wellness topics, including managing their chronic
conditions.
• Monitor vital signs and recognize when a problem may be indicated.
Service coordinators also believe that as a nurse the health educator often has greater
professional authority with residents than they do as a service coordinator. Not only can the
health educator provide a more detailed explanation about health-related issues, some residents
will follow-through on the health educator’s advice simply because they are a nurse. “Residents
trust her more because she’s a nurse,” says one service coordinator, “She can say this is a good
idea to do this or that; they are more receptive.” Another says, “If I try to talk to them about
nutrition and what causes diabetes, they don’t listen to me. They say you don’t know what you’re
talking about. She has more credibility.” Service coordinators also feel that as a fellow heath
professional, the health educator can also often obtain greater access to and/or a better response
from physician offices.
Evaluation of the WellElder Program
35
The WellElder staff believes that layering the skills of the health educator with those of the
service coordinator allows them to better serve the residents. “Working together has helped us
look more comprehensively at what is going on with individual residents,” says one service
coordinator, “We often bounce ideas off one another as we try and come up with a plan or
strategy to help residents age in place. Our outlook is more holistic and that benefits residents a
great deal.” “We can go visit people together and we see people from different perspectives,”
says another service coordinator. “For example, we’ll go visit someone when they come home
from the hospital,” says the health educator, “I’m looking at the medications, she’s looking at the
refrigerator.”
As a team, the WellElder staff believe they are able to offer residents a range of benefits,
including:
•
Access and maintain benefits and services. WellElder staff can help residents navigate the
complex network of benefits and services to identify resources to meet their needs. More
importantly, they can assist residents with the initial application process and subsequent
recertifications so that they maintain their benefits. Applications for benefit programs can
often be daunting—particularly for persons whose primary language is not English or who
have limited literacy—requiring applicants to fill out multiple forms and provide various
forms of documentation. WellElder staff can help ensure residents gather the correct
information and follow through on all necessary steps to complete the process. Some
examples of how WellElder staff helps participants with benefits and services include:
− The WellElder team conducts mock interviews with residents applying for the In Home
Supportive Services (IHSS) program so they know what to tell the interview about their
health and functional status situation to get the hours they need.5 They also educate
family about how the IHSS program runs so they can act as a liaison as well.
− WellElder staff can help residents adjust their benefits to match their needs. For example,
a resident who receives assistance through the IHSS program may need temporary
additional support after returning home from a hospital stay, and WellElder staff can
assist them with getting this increase in place quickly.
− The WellElder team helps residents with selecting their Medicare Part D plans. While
they do not make the decision for them, they explain the options, suggest they confer
with their doctor or pharmacist, and connect them with the local Health Insurance
Counseling and Advocacy Program (HICAP).
− The WellElder team helps residents to understand their benefits—particularly health
insurance coverage—and changes that occur over time. They sometimes protect residents
from unscrupulous sales people who are not always honest about coverage and costs. One
resident, for example, switched to a plan in which his physician did not participate and he
was billed for a visit. Another individual wanted to drop his Medicaid coverage, but was
unaware that the program was covering his Medicare premium.
•
Timely access to health care information and advice. With WellElder staff located in the
building, residents can simply walk downstairs to ask questions and get information rather
5
IHSS is a Medicaid program in California that provides people who are blind, disabled or elderly with personal
assistance and in-home support services to help them live safely in their homes.
Evaluation of the WellElder Program
36
than trying to connect with their doctor’s office where they may not be able to get an
appointment for several days or weeks. Examples of issues addressed by the WellElder staff
include:
− Some residents like to test whether they really need to take their blood pressure
medication. While the health educator might advise against this decision, they can help
them monitor the impact should they stop taking their medication.
− Residents can visit the health educator when not feeling well and the health educator can
help assess what might be happening and whether they need to see their doctor.
− For residents who have had a change in their medication regimen, the health educator can
help explain why their doctor made this decision, alert them to possible side effects of the
new medication and set up a plan to help them monitor the effectiveness of the new
prescription. For example, if they changed the resident’s blood pressure or pain
medication, the health educator may have the resident check in biweekly to take their
blood pressure or to rate their pain on a scale of 1-10.
•
Improve self-care abilities. Through group education sessions or one-on-one contact, health
educators are able to teach residents about disease processes and how to monitor and manage
their chronic conditions. For example, they can educate a newly-diagnosed diabetic on how
to take and monitor their blood sugar or teach a resident about a new prescription and the
best way to administer the medication. A distinct advantage is that the health educator is
located on site and has flexible time. WellElder staff say residents often leave their doctor’s
office having been given no education on a new diagnosis or not really understanding what
their doctor told them. In a low stress environment, the health educator can spend the time
the resident needs to understand, can present information in a manner they can comprehend
and is accessible for follow-up when needed.
•
Facilitate communication with health care providers. Assistance with communication can
happen in a variety of ways. The health educator can help prepare residents for a doctor’s
appointment by advising them on information to give and/or questions to ask their doctor
about themselves. Sometimes, the WellElder staff will call a physician with a resident or on
their behalf to discuss the resident’s issues. One health educator noted that the phone
frightens many residents, particularly those whose primary language is not English. She can
be a connection to their doctor to help get their questions or concerns addressed. WellElder
staff also note that many elderly residents have a deep reverence for their doctor because of
their professional status and are often unwilling to question them. In instances where the
WellElder staff perceive a doctor may not be adequately addressing a resident’s situation, the
WellElder staff can either convince the resident to push further with their doctor or assist
them in communicating with the physician. The health educators can also help residents
provide their physicians with documentation of their health situation. For example, some
residents get stressed in the doctor’s office and the blood pressure readings are high. The
resident, however, can share their record of blood pressure readings taken by the health
educator that shows their blood pressure is normal.
•
Enhance sense of empowerment. WellElder staff believes that through the guidance give
residents, some feel more empowered about managing their health care. For example, the
health educators believe that the regular monitoring of residents’ blood pressure helps them
Evaluation of the WellElder Program
37
to see that they are doing things appropriately to maintain a healthy level. One service
coordinator related the example of a resident with Parkinson’s disease who started regularly
attending the group education sessions. After one discussion that highlighted some principles
on healthy aging, he became more interested in his nutrition and incorporating activities into
his life that he used to love doing like reading and going fishing.
•
Support transitions home from the hospital or nursing home. WellElder staff note that they
frequently help smooth residents’ transitions back home from a hospital or nursing home.
This can include communicating with the discharge planner, the resident and/or the family
member about whether they are, in fact, ready to come home and have all the necessary
supports in place. There are times when a resident is insistent on returning home before they
are safely ready, and WellElder staff can try to convince them that it would be better for them
to remain in the hospital or nursing home. They can also help convince them of the benefits
of doing follow-up therapies. WellElder staff can also alert discharge planners to the realities
of the resident’s environment and whether they have the necessary resources and supports.
WellElder staff is also available to monitor residents after their return to help ensure they are
managing successfully.
•
Increased sense of security. The cumulative benefit of the program, WellElder staff believes,
is that it provides residents a sense of security that the property will support them with their
current and future needs. “They find it comforting to know that they have someone right here
in the building who is watching out for them and who can get them further help, if they need
it,” says one health educator. A service coordinator echoes this, saying, “We hear from so
many people that there’s a sense of comfort knowing there’s someone here; that we’re
downstairs and they can come talk to us.” Another service coordinator says, “Sometimes
residents say things like I don’t need you now, but when I do it’s nice to know you’re here.”
This perception was supported in the resident self-administered survey, where a majority of
program members responding said they felt safer knowing that someone was available to
answer their questions and keep an eye on them. They felt that they would be able to stay in
their apartments longer because of the assistance they receive (see Table 4.1).
WellElder Staff Perceived Benefit to Others
In addition to directly benefiting residents, the service coordinators also believe the health
educator enhances their own capacity to assist residents. As the health educator is at each
property a limited number of hours each week, they can provide the service coordinator with
information they should give or questions they should ask when talking with a physician’s office
or discharge planner to get better results. One service coordinator says, “Sometimes if you don’t
know the answer to the question already, you might not get the services. For example, “I might
ask [the health educator] ‘do you think this person could benefit from home health’ and then she
can tell me what to discuss with the discharge planner. She can help make my argument
stronger.” The health educator can also give the service coordinator insight on a resident’s health
situation and what kind of services they may benefit from now or in the future.
WellElder staff believes the program also benefits other entities, including:
Evaluation of the WellElder Program
38
•
Family members – Family members are not always aware of the services and resources
available in the community and WellElder staff can educate them about the various options.
Some family members will contact the WellElder staff for advice on what to do when their
family member is in the hospital. They will give them information on what to be aware of
and what to ask the doctor and discharge planner about. WellElder staff can also collaborate
with a family member to influence a resident’s actions. One service coordinator says,
“Sometimes I have family members who says ‘my father won’t listen to me, but he’ll listen to
you.’ Sometimes residents just don’t want their children telling them what to do.” Staff also
thinks they provide some family members with peace of mind. “We’ve heard from the
families, ‘I’m so glad you’re here and I have someone to talk to,’” says one staff member,
“They have a sense of relief when there is an incident of ‘oh my mom can come see you.’”
•
Property managers – WellElder staff believe they are able to avert many residents from
lapsing into crises, which can lead to disruptions to other resident in the building and/or
potential damages to the property. Property managers generally do not have the skills or
knowledge to deal with resident health-related problems, particularly mental health issues.
The WellElder program helps property managers focus on property maintenance and
operations.
•
Discharge planners – WellElder staff can help discharge planners have a complete picture of
a resident’s situation. They can help them understand what supports they do and do not have.
WellElder staff can also assist them with putting services and supports a resident may need in
their transition in place. One service coordinator says she often hears from discharge
planners, “I didn’t know you had this service. That’s great; can you do this or that?” Several
discharge planners, WellElder staff says, have said they wish all properties had someone like
this.
•
Paramedics – Paramedics have found it beneficial to have the WellElder program, staff says,
because it helps them know more about a resident than the resident is often able to tell them.
They have particularly found the medication lists the WellElder program helps residents
maintain valuable.
•
IHSS Aides – A large number of residents in the four properties participate in the IHSS
program. Some aids will come to the WellElder staff with concerns about the resident they
care for and the service coordinator and/or health educator can give them advice or engage
with the resident with them. This is generally more common for residents who do not have
family members in the area or have more complex situations.
Perception of Property Management
The majority of property managers echoed the benefits of the WellElder program to the residents
perceived by the WellElder staff. (One property manager was less supportive than the others,
indicating that resident problems were often resolved by property management itself). These
include the easy access to the service coordinator’s and health educator’s wealth of knowledge
right in their building and the encouragement of residents to address health problems they might
not follow up with on their own. One manager gives an example of seeing the health educator
look at a resident’s swollen leg in the lobby, which had apparently been worsening over time.
Evaluation of the WellElder Program
39
She told the man that this could be a serious problem and it was very important that he see his
doctor. Managers also believed that the advocacy and communication assistance the WellElder
team can provide residents with health providers is a major benefit.
Property managers identify different groups of residents who benefit most from the WellElder
program, although they think the program can help all residents in some way. One manager
believes residents who are declining benefit greatly because, through the team approach, the
service coordinator and health educator can identify and figure out the best ways to address their
various problems. Another believes the residents who are receptive and open to receiving
education and assistance gain the most. The manager believes the support the program offers
helps these residents thrive and stay independent. “Residents who are frail and participate are
just more engaged in life; those who are frail and don’t are more isolated,” this manager
perceives, “Residents who are not engaged could be in their apartment hurting and nobody is
checking on them because they don’t want anyone to know.”
The majority of property managers also believe the WellElder program benefits the property in a
variety of ways. One notes that the program minimizes the time the property staff spends dealing
with resident-related issues, which allows them to focus on their property operation and
maintenance responsibilities. Another manager feels the program helps minimize resident
turnover. By helping residents address their physical and mental health issues, managers feel the
service coordinator and health educator help minimize damages to the property and disruptions
to the community and other residents. For example, if a resident has a hoarding/cluttering issue
that creates an unsanitary environment and puts them out of compliance with their lease, the
service coordinator and health educator can help address the issue. If a resident forgets to pay
their rent, they may just need a system to remind them or assistance with managing their finances
and the WellElder staff can help identify a resource. If a resident is wandering the halls and
invading other residents’ space, the service coordinator and health educator can help identify a
solution. One property manager believes he sees fewer inter-resident conflicts compared to
previous property at which he worked. This could possibly be due to the service coordinator and
health educator identifying behaviors that may be due to underlying health issues and helping
address them before they escalate.
One property manager notes that the coordination of what the service coordinator and health
educator bring to the property helps the property management staff do their job better. “If we
have more satisfied residents we have a happier, healthier community,” the manager notes, “We
can provide a well-managed environment, but it takes all of us to make it successful. They bring
a piece of the puzzle that we can’t.” Another property manager echoes this sentiment. “Any
building that doesn’t have a service coordinator or health educator is really going to feel it. The
quality of life for seniors is based on more than just a building; it’s important, but they are
dealing with much more. That’s the job of the WellElder program.”
Almost all the managers concur that they would like to increase the health educator’s
availability. “I don’t think we have enough time for the health educator,” says one manager, “It
would be better if we had double or triple the time; I think we are probably just barely scratching
the surface.” This manager and others believe resident needs are increasing and the potential
places for them to move to for additional support are limited.
Evaluation of the WellElder Program
40
Resident Perceptions of the WellElder Program
In the resident self-administered survey, WellElder program members were asked whether and in
what ways they believe the program (also identified for them as the service coordinator and
nurse) helps them. Across the four properties 93.1% of respondents believed the program was
helpful (Property 1 – 92.4%, Property 2 – 96.4%, Property 3 – 89.2%, Property 4 – 94.9%). As
Table 4.1 shows, approximately two-thirds of residents across the four properties believed the
program helped them identify resources and services and access them more quickly than they
would be able to on their own. For a large majority of members across the four properties, the
program also brought a sense of safety and a belief that the program will help them remain
longer in their apartment.
Table 4.1: How the WellElder Program Helps Residents*
Property 1
Property 2
Property 3
Property 4
Total
57.4%
66.1%
66.1%
79.0%
66.7%
Helps me get services and assistance
quicker than I can get on my own.
58.8
48.2
66.1
77.2
62.5
Helps me understand my health
situation better.
29.4
51.8
46.4
66.7
47.7
Helps me understand how to better take
care of my health care needs.
36.8
41.1
51.8
71.2
49.8
Helps me avoid medical emergencies
and going to the emergency room.
16.1
26.8
27.3
49.1
29.2
My doctor is more responsive to me
because I know what to tell him or her
about myself and what questions to ask.
41.2
25.0
27.8
66.7
40.4
I feel healthier.
10.3
32.1
29.6
43.8
28.1
I have a better sense of well-being.
19.1
37.5
25.9
45.6
31.5
I feel safer knowing that someone is
available to answer my questions.
59.7
71.4
57.4
77.2
66.2
I feel safer knowing that someone is
keeping an eye on me.
48.5
51.8
42.6
71.9
53.6
I will be able to stay in my apartment
longer because of the assistance I
receive from the nurse and service
coordinator.
54.4
60.7
66.0
80.7
65.0
Helps me find out about resources and
services I am not aware of.
*Respondents were allowed to select multiple answers.
Almost all members who responded to the self-administered survey across the four properties
said they would recommend the program to a friend or neighbor (Property 1 – 96.7%, Property 2
– 94.9%, Property 3 – 92.5%, Property 4 – 94.6%).
Evaluation of the WellElder Program
41
In focus groups with members of the WellElder program, most participants could not identify
with the formal name of the program, but were aware of the service coordinator and the nurse, if
not by title then by name.
Most focus group participants had received assistance from the service coordinator and
exuberantly praised the support they receive from them. Although this study attempted to look at
the role of the service coordinator with respect to the WellElder program, residents do not
differentiate the complete range of assistance that the service coordinator provides them.
Participants talked about the wide range of support and assistance the service coordinator
provided, from helping them resolve issues with the cable company and social security and their
health insurance to helping them arrange home delivered meals and visiting them in the hospital.
Personal interaction with the health educator was more varied among the focus group
participants; some had personally visited the health educator, others had not but knew of fellow
residents who had. To some extent, the lower level of interaction with the health educator is due
to the limited amount of time the health educator is at the property and the narrower range of
assistance they provide relative to the service coordinator. Participants did note receiving
assistance from the nurse in a variety of areas, including preparing a list of their medications,
having their blood pressure checked, information and advice about their diseases and
medications, advice about whether they needed to follow up with the doctor about something,
support caring for a spouse after they returned from the hospital, understanding medical test
results and visits following a hospital stay to see how they are doing.
When asked why they did not utilize the health educator at all or more frequently, participants
provided a range of reasons. Some residents said they got all the health information they needed
from their doctors. Some said she is not available that often, and that they often go to the service
coordinator with their health-related questions and concerns. Several were frustrated by what
they perceived to be restricted services by the health educator. They did not understand why the
nurse could not provide traditional nursing services like checking wounds, administering first aid
and giving shots. Several also wanted the nurse to be available in a capacity that could prevent
them from having to call 911. It appeared some participants may possibly have limited
interaction with the health educator because they are unaware or confused about what the health
educator could or could not help them with. One participant, for example, wished they could help
with understanding his medications but believed he had to go to a pharmacist for that.
Some participants noted that the health educator had visited them following a hospital stay or
they were aware that they had done that for other residents and they expressed great appreciation
for this service. A few participants said they had not received visits following a hospital stay and
were disappointed by this. It appeared that some residents may feel worried or vulnerable when
returning from the hospital and were comforted by the fact that someone is checking on them and
aware of them.
The participant response was mixed on whether they attended the group education sessions and
activities in their properties. Some who did said they had learned helpful information from them.
One of the reasons given for not attending was the language barrier, particularly for Russian-
Evaluation of the WellElder Program
42
speaking residents because the sessions are not currently translated into Russian. Others said they
forget they are occurring or that they are too busy to go.
Echoing the results from the resident survey, participants in the focus groups seemed to be very
comforted by having the service coordinator and health educator there to help them with their
questions and situations and to know that someone is aware of them and watching out for them.
Differences between Members and Non-Members
The research team analyzed the resident self-administered survey, looking at resident reported
characteristics and service use, and resident incidents and move outs to identify differences
between WellElder program members and non-members.
Resident Characteristics
Table 4.2 highlights where statistically significant differences were found between the
WellElder program members and non-members in the areas examined in the resident selfadministered survey. Compared to non-members, WellElder program members:
• Are older;
• Have lived in the property longer;
• Have higher levels of difficulty with shopping, housekeeping, doing laundry and
traveling to places out of distance;
• Have higher levels of experiencing multiple ADLs and IADLs;
• Have higher levels of arthritis or rheumatism;
• Are more troubled by pain;
• Take a higher average number of prescription medications and over-the-counter
medications; and
• Report a higher average number of days in the last 30 days that their health was not good.
The full survey results analyzed by membership status can be found in Appendix B.
Evaluation of the WellElder Program
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Table 4.2: Differences between WellElder Program Member and Non-Member Characteristics
Member
Non-member
P-value
Mean age (years)
78.7
74.5
.0005
Mean length of time in building (years)
9.2
6.3
<.0001
51.4%
38.0%
.0265
Difficulty with ADLs/IADLs
Shopping
Housekeeping
61.9%
43.0%
.0014
Doing laundry
49.1%
37.0%
.0462
Traveling to places out of walking distance
54.3%
40.6%
.0201
1 or more ADL
58.2%
41.0%
.0019
2 or more ADLs
39.1%
28.0%
.0420
Difficulty with multiple ADLs
Difficulty with multiple IADLs
1 or more IADL
75.7%
64.1%
.0241
2 or more IADLs
69.1%
46.6%
<.0001
Health Conditions
Arthritis or rheumatism
71.3%
54.3%
.0024
78.1%
64.1%
.0083
Mean number of prescription medications
6.2
5.2
.0317
Mean number of over-the-counter medications
2.4
1.8
.0126
Mean number of days health was not good in
last 30 days
12.8
9.5
.0314
Often troubled with pain
Resident Service Use
One goal of the WellElder program is to help connect participants with home and community
based services that can assist them with their health and supportive services needs and help
facilitate their ability to remain safely in their apartment. Residents were asked in the selfadministered survey about their use of the services listed in Table 4.3. Comparing program
members to non-members, members report a statistically significant higher use of transportation,
homemaker, personal care, exercise and case management services. After adjusting for the
property, age and presence of at least one ADL or IADL, the difference between member and
non-member service use were attenuated in all areas except for homemaker services. The odds of
a WellElder program member using homemaker services are almost three times that of a nonmember.
Evaluation of the WellElder Program
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Table 4.3: Differences between WellElder Program Member and Non-Member Service Use
Member
% (number using
service)
Non-member
% (number using
service)
Unadjusted
P-value
Adjusted Odds
Ratio (95% CI)*
43.6% (122)
28.0 (28)
.0062
1.53 (0.87-2.69)
Homemaker services
71.7 (208)
46.2 (48)
<.0001
2.87 (1.44-5.73)
Meals programs
23.5 (64)
18.6 (19)
.4016
1.38 (0.74-2.56)
Assistance with medications
30.1 (84)
20.6 (21)
.0707
1.00 (0.53-1.89)
Personal care assistance
32.3 (91)
21.6 (22)
.0434
0.92 (0.45-1.85)
Adult Day Care
9.6 (25)
5.8 (6)
.3009
1.17 (0.40-3.42)
PACE
4.1 (10)
5.1 (5)
.7715
0.64 (0.17-2.38)
Exercise programs
27.5 (72)
16.0 (16)
.0279
1.83 (0.95-3.54)
Mental health counseling or therapy
18.8 (49)
15.2 (15)
.4451
1.17 (0.55-2.48)
Case management
6.7 (17)
1.1 (1)
.0313
NA
Bill paying assistance
13.8 (37)
17.0 (17)
.5074
0.45 (0.22-0.94)
Services
Transportation services
*Adjusted for property, age, presence of at least one ADL or IADL.
Although the differences in service use among program participants and non-participants
disappeared when controlling for certain variables, this does not mean the WellElder program
does not help increase service use among program participants. All residents in the four
properties, whether members of the WellElder program or not, can receive assistance from the
service coordinator. Service coordinators are likely informing any resident they see about
services and supports that may benefit them and assisting them in accessing the services.
Resident Incidents
WellElder staff attempt to monitor resident incidents such as falls, 911 calls, emergency room
visits and hospital stays. In the event of an emergency, residents may call 911 directly or alert
building security who then calls 911. If a service coordinator and/or health educator is on duty
and alerted to the emergency, they will check on the resident. When emergencies happen in the
evening or on the weekend, WellElder staff and property management are alerted to the event by
incident forms completed by security staff. When receiving an incident from, the service
coordinator and health educator generally try to ascertain the status of the resident, including
whether the resident was taken to the hospital and, if so, if they are still there. If the resident did
not go to the hospital or has already returned home, they might visit him or her in their
apartment. If the resident is still in the hospital, they would attempt to find out their situation and
connect with the discharge planner. The hope would be to ensure the discharge planner is fully
aware of the resident’s living situation and puts in place the necessary supports for the resident to
have a successful transition back home. WellElder staff will attempt to visit residents in the
hospital or nursing home when warranted or as circumstances allow. This may be when a
resident has an extended stay or has a complex situation they have been assisting with.
Evaluation of the WellElder Program
45
WellElder staff face several challenges in attempting to follow-up with residents during a
hospital visit. Because there are multiple hospitals in the area and residents have different
insurance providers, they are not always aware where residents are taken to. Due to HIPAA laws,
hospitals may or may not confirm a resident is there. For this same reason, discharge planners
may be unwilling to discuss a resident’s situation with the service coordinator or health educator.
WellElder staff has been able to establish relationships with some discharge planners and make
them aware of the housing property and the presence of the WellElder staff. Some discharge
planners will call the property to find out more about the resident and their living situation.
When WellElder staff can connect with a discharge planner, they often work in partnership with
them to get needed supports in place. However, due to the multiple hospitals, the large number of
discharge planners and staff turnover, many are not aware of the housing property. In addition,
WellElder staff may not always be aware when a resident has gone to the hospital. Some
residents may be sent to the hospital directly from their doctor’s office or may have an
emergency while out of the building.
WellElder staff do not have a formal protocol for following up with residents when they return
home from an ER visit or hospital or nursing home stay. If they are aware a resident has returned
home, the service coordinator and/or health educator generally attempt to follow-up with them.
They would check to see if they have all the necessary supports in place to have a successful
recovery. For example, if home health was ordered has it started, if they had an IHSS aid or other
service has it resumed, do they have adequate groceries, etc.
Hospital visits and post-hospital follow-ups are most often handled by service coordinators,
primarily due to the limited time the health educators are at the property. The San Franciscobased health educator does make occasional visits if her day at the property coincides with a
resident’s stay and she does attempt to follow-up with residents when they have returned to their
apartment. The service coordinators also generally update her about residents who have returned
from the hospital. In the San Jose property, the health educators do not conduct hospital visits
and do limited follow-up visits because they may not be at the property on the day a resident
returns home.
Each of the four properties tracked the number of resident incidents—including falls, 911 calls,
emergency room visits, hospital stays and nursing home stays—during the eight-month data
collection period. Table 4.4 shows the number of incidents experienced by WellElder program
members and non-members in the combined four properties, as well as the over all number of
episodes. In a single episode, a resident may experience multiple types of incidents. For example,
in one episode a resident may call 911, be taken to the emergency room and admitted to the
hospital. As Table 4.4 shows, a resident seldom had only a 911 call or an emergency room visit.
Evaluation of the WellElder Program
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Table 4.4: Number of Resident Incidents
Type of incident
Member
(N=668)
Non-member
(N=297)
Episodes
138
38
Fall
29
8
911 call
95
26
911 call alone
5
1
Emergency room visit
87
27
Emergency room visit alone
6
1
Hospital stay
83
20
Nursing home stay
19
3
Table 4.5 shows the percentage of WellElder program members and non-members with at least
one type of incident during the eight-month data collection period. A higher proportion of
program members experience each of the various types of incidents tracked than non-members.
Table 4.5: Percent of Residents Experiencing Incidents
Member
(N=668)
Non-member
(N=297)
13.8%
9.8%
Fall
3.3
2.4
911 call
10.5
7.4
Emergency room visit
9.9
7.4
Hospital stay
9.3
5.7
Nursing home stay
2.4
1.0
Type of incident
Any incident
The discrepancy between the proportion of residents reporting falls, ER visits and hospital stays
in the resident self-administered survey and tracked by the WellElder and property staff over the
study data collection period must be acknowledged. Importantly, the difference in time frame
must be noted. Residents were asked about events experienced during the past year, while the
housing properties collected data over an eight-month period. Other possible reasons for the
differences include: 1) residents over reported their events or 2) the properties cannot
consistently track all resident events due to the challenges and limitations discussed above.
Resident Move Outs
Table 4.6 examines the move outs of WellElder program members and non-members over the
course of the eight-month data collection period and where residents relocate to after moving
out. A small proportion of both groups moved out during the study period. In both groups, the
most common reason for move out was due to death. A slightly higher proportion of nonmembers moved out to a nursing home facility. It is possible some of these non-members did not
seek the WellElder team’s assistance in managing their health and functional conditions or
accessing services and supports that might have enabled them to remain in their apartment.
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Table 4.6: Resident Move Outs and Destination
Member
(N=668)
Total move outs
Non-member
(N=297)
30
15
4.5%
5.0%
Other apartment property
3.3%
13.3%
Family
30.0
13.3
RCFE/ assisted living
6.7
6.7
% of group population
Destination (% of total move outs)
Nursing Home
16.7
26.7
Death
43.3
33.3
0
6.7
Other/unknown
Program Participation
Service coordinators and health educators were interviewed about differences they may see in
residents’ willingness to participate in the WellElder program, accept assistance and utilize
services, including any distinctions they might perceive between different ethnic or cultural
groups.
Less Likely to Participate
One property believes more functional and healthier residents are least likely to participate in the
WellElder program. These individuals are often active outside of the building—as caregivers for
their grandchildren, working, volunteering, etc.—and are not coming to WellElder activities. In
this building, staff sees the Chinese residents as less involved because they are a younger,
healthier group. This is not to say healthier, active residents are not engaged in the program,
though, staff says. There are some residents who still want the contact and reassurance that they
are doing well.
Another property thinks residents with engaged family members may be less likely to participate
in the program. They also believe there may be some residents who are fearful of telling any
property staff about their problems. “I’ve had some people say no matter what you say about the
confidentiality, I know you people have meetings and they may ultimately squeeze it out of
you,” says a health educator. Some residents, staff believes, just are not joiners and have been
that way their entire life.
Receptivity to Assistance
Service coordinators feel residents are generally open to their advice and usually follow through
on their suggestions. They believe this is due to the trusting relationship they are able to form
with residents. As one service coordinator stated, “People seem to know why we’re here and
what we’re doing; they know we’re dedicated to that service lifeline.” Service coordinators say
they spend time building trust because “the goal is to get residents to come back and be open to
referrals and services.” Being on site facilitates such relationship building. It allows service
coordinators to meet with residents on their terms, in a low-stress environment. Residents see
them regularly and view them as a part of the fabric of their community. Building trust and
Evaluation of the WellElder Program
48
report with residents is essential, one service coordinators says, “before you can get to the
deeper, heavier issues.”
While most residents are receptive, WellElder staff say it can depend on the person. One service
coordinator says they sometimes need to get family on board or tag team with a physician to
present a united front in order to influence a resident’s decision. Residents are also sometimes
more receptive to some services than others. For example, residents are generally open to having
an IHSS aid or receiving vouchers for taxi services. Many, however, do not want to use Meals on
Wheels because they do not like the food or do not like having to be home during a particular
time window. Mental health issues are very difficult to address with residents due to the
associated stigma, which can be very strong in some of the cultures in the building. One service
coordinator says, “We try to not use the terms like therapist, mental health, etc. That works for
some.”
Service coordinators say it can take a while to get some residents to follow-through, but
eventually they often come around. For example, many residents have deep respect for their
doctor and do not want to offend them. When WellElder staff believes a physician is not
addressing a resident’s problems, it can be difficult to get the resident to question their doctor or
be more forceful with them. With residents who do not follow through, service coordinators say
they can sometimes convince residents to let them take action for them. For example, they can
call a resident’s doctor and explain to them what the resident is experiencing. This is only done
with the resident’s permission, however. While staff wants to help residents resolve their
problem, one service coordinator says, “We also don’t want people to not come back because we
violated their choice.”
Challenging to Serve
WellElder staff concur that residents with mental health issues (including mental illness and
cognitive diseases such as dementia) are the most challenging to serve for multiple reasons. For
residents with physical challenges, there are a variety of available services and individuals are
generally amenable to using them. However, it can be very difficult to convince persons with
mental illness to even acknowledge their illness much less accept services. Due to the stigma
associated with mental illness, particularly strong in some cultures represented in the building, it
can be hard to even begin a discussion about such problems. When a conversation can be
initiated, the illness can trigger a poor reaction. A resident may become angry, deny the problem
and possibly no longer be willing to come to the WellElder staff again. There is also a lack of
mental health services, particularly for non-English speaking residents, to connect residents with.
Because of the independent nature of the building, it is also hard for program staff to know if
residents are already being followed by anyone or are taking their medications.
Program staff also find individuals with dementia challenging to serve. The ability for these
residents to remain in the building is often case by case, staff say, and is driven by the severity of
the disease and/or the resources that program staff can put in place. A resident with dementia in
one property is supported by her daughter, who is a live-in caregiver. The health educator has
educated the daughter on ways to help keep her mom safe. In response to concern that her
mother had taken a double dose of blood pressure medication, for example, the health educator
discussed safe ways to handle and administer her mother’s medications. She also discussed
Evaluation of the WellElder Program
49
general home safety measures, which may be necessary if the mother’s dementia worsens, like
an alarm on the door to prevent wandering, keeping sharp kitchen tools out of reach and
monitoring the water temperature in the shower and bath. Another resident in this property with
dementia has a social worker in her doctor’s office who works with the service coordinators to
ensure the resident remembers appointments and gets transportation to the doctor’s office to
maintain regular medical care.
Individuals fiercely hanging on to their independence are also difficult to serve. One service
coordinator described seeing residents on the cusp of a crisis that you might be able to prevent,
but who refuse services or altering their practices. For example, a resident who does not want to
use a cane, putting them at risk for falling, or does not want a home care aid, limiting their ability
to care for themselves or their home. This desire and behavior, the service coordinator believed,
is evident across all cultures in the building.
Cultural and Ethnic Differences
WellElder staff believe the Russian and Chinese residents are generally well connected to
services and resources in the community. These groups have a variety of ethnic-affiliated
organizations such as social service agencies, cultural organizations and churches through which
they have been educated about and/or linked with services. They also often learn from their
fellow residents about available resources.
The health educator in the San Francisco properties, which have the largest Russian populations,
believes Russian residents do not access her as frequently as other ethnic groups in the
properties. She perceives Russian residents are often on top of managing their own health and
support needs. As just discussed, this is partially due to their engagement with Russian-affiliated
community groups who have educated them about and connected them with services. Some
Russian residents were also health-care professionals before immigrating to the U.S. and feel
they can manage their own care. Other Russian residents also sometimes go to them for advice
and assistance. The health educator also perceives that Russian residents tend to be more private
and do not want staff to know their business.
The same health educator believes Chinese residents tend to utilize her more frequently. They
actively come to her for blood pressure monitoring and she finds they are generally compliant
with her advice and suggestions. WellElder staff in the San Jose property also find the Chinese
community is very proactive in getting its needs met and these residents often initiate contact
with them. They believe Chinese residents are generally very open to education activities and
continued learning.
Some staff perceives the White and African American residents tend to be less knowledgeable
about resource options and are sometimes reluctant to accept services. They sense they often
have to do more outreach with these populations and encourage their participation in activities.
To some extent, the San Francisco-based health educator perceives utilization and interaction is
influenced by language ability. At one property with a Chinese-speaking service coordinator,
Chinese residents come to her frequently because the service coordinator can help interpret. They
also actively seek out the service coordinator. In the property with the Russian-speaking service
Evaluation of the WellElder Program
50
coordinator, the health educator finds Russian residents are not as active with her, but they
frequently engage with the service coordinator. She believes Chinese residents in this building,
however, do not see the service coordinator as often.
Although mental health issues are difficult to address in general, some program staff believe it is
more challenging with Chinese residents. Mental illness is a taboo subject in the Chinese culture
and many residents are reluctant to talk about such problems outside of the family. Staff in one
property avoid using the term “mental health” and instead try to frame the discussion in terms of
a possible complication of medications or an aging/memory-related issue. WellElder staff also
find it challenging to address end of life issues in both the Chinese and Russian communities.
Death is commonly an unmentionable subject in these two ethnic groups.
Evaluation of the WellElder Program
51
Chapter 5: Conclusions and Recommendations
The findings from this multifaceted study provide important insights into how the WellElder
program was developed and implemented in four northern California housing properties, how
participants and non-participants differed in terms of their demographic characteristics and
broader service utilization and the perceived benefits of the program. This study also identified
key elements of the program that are likely to enhance the potential for replication in other
housing properties as well as areas that require modifications or improvements to increase the
likelihood that the program will be consistently successful in achieving its goals. The remainder
of this chapter provides a more detailed discussion of the study’s implications and
recommendations for improving the program.
WellElder Implementation
The research team found that the WellElder program was “home grown” in response to both a
real and perceived need for a team approach that augmented the capacity of the service
coordinator in each property with a nurse health educator. The role of the nurse evolved over
time and continues to evolve with a focus both on individual health monitoring and group health
education.
While there was general agreement across upper management at the corporate and individual
property levels about the potential contribution of a nurse to the health and well-being of
residents, the case studies within the four properties indicate that the WellElder program was not
implemented consistently across the organizations. This variation occurred, in part, because of
differences in the philosophy of one of the housing property managers concerning the role of the
WellElder program. Other reasons for this variation in program implementation included the lack
of a formal definition and related policies and protocols that would facilitate more consistent
implementation and differences in the degree of financial investment in the program by
individual properties.
Impact of the WellElder Program
Findings from the resident survey and focus groups indicate that residents received a wide range
of supports and assistance from the WellElder team with managing their health-related issues
and concerns. In both the survey and focus groups, residents expressed their belief that the
service coordinator and health educator helped them identify resources and services and access
them more quickly than they would be able to on their own. They also found comfort in knowing
that someone was available to assist them and believed the program will help them remain longer
in their apartment.
The residents, the WellElder teams and the majority of the housing property managers saw great
value in the onsite presence of the health educator and service coordinator. The major benefits
included:
• Helps build trust – Having the service coordinator and health educator onsite allows
residents easy access in a low stress environment. Residents see the staff daily and accept
Evaluation of the WellElder Program
52
•
•
•
•
•
•
•
them as part of the fabric of their community. They also see and hear about other
residents benefiting from their assistance.
Helps build insight about residents – Easy access allows for frequent interaction, which
helps the service coordinator and health educator to know residents’ normal state and
recognize when changes are occurring. It also allows them to learn a resident’s values
and interests.
Encourages follow through – Trust plays a significant role in resident willingness to
follow through on the service coordinator’s and health educator’s advice and to accept
services that they might otherwise be reluctant to utilize. The WellElder team’s
knowledge of residents can also help understand mechanisms to motivate them to utilize
services they believe will benefit them.
Resolves complex problems – Some problems and situations may require multiple steps
to resolve. An onsite presence makes it easier for the service coordinator and health
educator to continue to support a resident in following-through on problems that may be
difficult to understand or require perseverance. This is particularly helpful for residents
who may have language barriers or cultural norms against questioning authority.
Substitutes for limited support network – The assistance the service coordinator and
health educator can provide is particularly important for residents who have no family or
have dysfunctional family situations where family members do not provide support.
Enhances existing support network – When family members are involved with supporting
residents, the service coordinator and health educator can give them additional insight
regarding a resident’s situation and can offer advice on solutions to problems.
Decreases resident anxiety – Some residents experience greater anxiety about their health
situations and need reassurance that everything is ok. With the health educator onsite they
have easy access to ask questions and receive advice. This may help reduce their anxiety
and perhaps reduce unnecessary visits to the doctor or emergency room.
Incorporates elements of effective care coordination – For some of the residents with
chronic illnesses and co-morbidities, the WellElder service coordinator and nurse health
educator team provides a framework for better care coordination with the hospital,
physicians and other providers. This program has the potential to be a cost-effective
approach to integrating the complex and fragmented service system for medically
complex, disabled individuals through the presence of the nurse and service coordinator
in the building and in residents’ apartments. The WellElder program provides an onsite
mechanism that can help monitor resident’s health situation, provide them education and
advice on managing their health conditions and help them access and communicate with
their health care providers.
This study found that the WellElder participants were older and sicker than those not using the
program. This finding suggests that the service coordinator and nurse health educator team was
successful in targeting those most in need of assistance in accessing multiple services and public
benefits and in engaging in practices that will help them remain in their apartments for as long as
possible. Although the study limitations do not allow the research team to address causality, the
findings suggest the service coordinator and health educator team does positively contribute to
residents’ ability to manage their health care, maintain their quality of life and safely age in
place. Despite their complex health situations, a smaller number of residents experience 911
Evaluation of the WellElder Program
53
calls, trips to the emergency room or hospital stays than might be expected. Among those
residents with a hospital stay during the study period, few appeared to have repeat
hospitalizations. While it seems that a number of residents might be eligible for nursing home
level of care, a small number of residents moved out of the property over the course of the study
period. A large portion of residents were able to stay in their apartment until their death and less
than half of those who moved out transferred to a higher level of care. These trends might
indicate that the WellElder program is helping residents to successfully manage their health and
functional needs.
Potential for Replication
The WellElder program has several elements that make it an attractive model for replication in
other affordable senior housing communities to help meet residents’ health-related needs:
• Considers the spectrum of need – The needs of aging, low-income seniors can be
complex and often involve interrelated health and social issues. Linking the skills sets of
a service coordinator with a health educator/nurse multiplies the chances of addressing
residents’ array of interdependent needs.
• Builds on existing infrastructure – The program builds on the service coordinator position
many senior housing properties already have.
• Relatively low-cost – The program does not require extensive start up costs and the hours
of the nurse can be scaled to the housing property’s available resources. The health
educator role can be contracted, eliminating the need to bring on an additional employee.
• Fits within various regulatory environments – Utilizing the nurse in an education,
coordination and supportive role, and not as a direct care provider, prevents independent
housing properties from bumping up against laws and regulations surrounding the
provision of care.
• Allows housing properties to stay within their comfort zone – The addition of the health
educator to the existing service coordinator model expands the knowledge and skills
available to address resident needs, but does not radically alter the type of support many
housing properties are familiar and comfortable with providing.
Recommendations for Improvement
Despite the WellElder program’s strengths, the study did reveal some challenges that may inhibit
the program from achieving its greater potential. Like many provider efforts, the WellElder
program was initiated and has evolved through informal grassroots efforts. After several years of
experience, the program could now benefit from some more purposeful and systematic direction.
Specific areas warranting special attention are described below.
Expanding the Health Educator’s Hours
The limited amount of time the health educator is available at each property may hinder the
position’s potential impact. In one property, the health educator is only present four hours a
week. Because several residents regularly utilize the time to have their blood pressure monitored,
the health educator has little time to assist residents in other ways. While monitoring blood
pressure is a valuable service, this activity leaves little opportunity for the nurse to see a wider
number of residents, build relationships that encourage WellElder participation, monitor
Evaluation of the WellElder Program
54
residents with more complex problems, assist with residents transitioning from a hospital or
nursing home stay or conduct group health and wellness activities and education sessions.
Even in the other San Francisco properties where the nurse is available for double the time, the
health educator is still primarily limited to reacting to residents through one-on-one office visits.
The health educator believes she could have a larger impact if she had more time to conduct
group programming, which a broader spectrum of residents may be likely to attend. Group
sessions allow for education and dialogue with a larger number of residents and expose residents
to a broader range of topics and activities. With the bimonthly health and wellness education
sessions in the San Francisco properties, the health educator believes residents are more engaged
and interactive than they were before the programs were initiated and that the group program
participants have gained familiarity with the WellElder staff.
More hours would also allow the health educators to expand their reach through one-on-one
contacts. Some residents who are currently not able to visit the health educators during the hours
they are on site might be more likely to check with the nurse before going to their doctor or the
emergency department. Greater health educator availability could, therefore, help to prevent
unnecessary hospital or physician visits. Expanded time at the property might also allow the
health educator to do more monitoring of and following up with residents with complex health
situations. Similarly, it might also allow the health educator to engage with more residents during
their discharge from a hospital or nursing home stay and transition back to their apartments.
WellElder staff across the four properties concurs that the health educator role would be
enhanced by more hours. The limited hours are primarily a function of lack of funding. Should
additional financial resources be found to expand the health educator’s availability, staff shared
some thoughts on how the expansion should be implemented. For example, the San Jose property
currently has a health educator position on site for 15 hours/week, but the time is split between
two individuals. The health educators in this property felt that in an ideal world the position
would be increased to full-time, with one individual filling the position. They expressed the
concern that when working multiple part-time jobs, there is the danger of the health educator
being pulled away from the WellElder site when unexpected needs arise in their other position.
The Institute on Aging, or any other entity from which health educators are contracted, should
commit to protecting the health educators’ time at the WellElder sites. The health educators
indicated that if a full-time position was not possible, it would be beneficial to at least have the
health educator present in each property for some time every day.
Clarification of the Health Educator Role
The health educator role has informally evolved since the WellElder program was first
implemented. This has occurred as implementation experience has been gained over time and the
nursing orientation of the health educator has changed with new hires. Given the insight gained
thus far and the evolution of the resident population and their needs, the WellElder program
should review the role of the health educator and more formally define the specific functions of
the position, including how the health educator operates as part of the WellElder team. Role
clarification and greater specificity would help create a more consistent understanding of the
program among all the participating properties and service partners as well as residents and
would contribute to greater consistency in program implementation.
Evaluation of the WellElder Program
55
NCPHS’ philosophy of aging in place relies heavily on residents using home and communitybased services (e.g., the IHSS program) to help meet their needs. Currently, one of the articulated
roles of the health educator is to inform residents of and encourage them to use communitybased resources. Given the information and referral role of the service coordinator in the
WellElder team, identifying this activity as a major role for the health educator may be
duplicative and somewhat distracting. By placing an emphasis on this task, the WellElder
program may not be defining the health educator’s functions in a manner that fully capitalizes on
the skills and knowledge a nurse brings to the WellElder team. The value added includes the
nurse’s ability to assess and educate residents on their health situations and mechanisms for
successfully managing their health care. Viewing the health educators’ strengths from this angle
might reprioritize their functions. Drawing a clearer distinction between the nurse and service
coordinator roles and emphasizing the health monitoring and health and wellness education
functions of the nurse would strengthen the program.
The WellElder program may also want to more clearly define the health educators’ role with
respect to more traditional nursing functions, such as giving flu shots, dressing wounds,
reviewing medications, etc. Many residents reported being confused by the health educator’s
role. Because the health educators are nurses, residents expressed frustration when the nurse
refused to perform more traditional nursing functions such as giving shots or dressing a wound.
“I get a lot of disappointed people,” says one health educator, “they say ‘you’re a nurse, why
can’t you do it’.”
While the health educator’s scope of practice was generally clear to the WellElder and property
management staff, the reasons behind the limitations on the traditional clinical role were not
always understood. Variation in answers included HUD regulations, state licensing laws for
independent housing settings or nurse practices, and NCPHS or IOA policy. To provide clarity
and ensure there is a rationale for not performing a function that some perceive might be
beneficial, the WellElder program should formally articulate the functions of the nurse health
educator and what the nurse cannot do within the scope of the WellElder program.
Assuming a More Proactive Role
WellElder staff generally functions in a reactive rather than proactive manner. To a large extent,
this is due to the limited time the health educator is available at the property. When on site, the
health educators generally spend the majority of their time in the office checking blood pressures
and responding to residents who approach them with their questions and needs. WellElder staff
note that their interaction with residents is often precipitated by an event or crisis.
The WellElder team does take preventive actions with residents, but on an ad hoc basis. The
service coordinator and health educator respond to situations as they identify them with
individual residents. For example, the health educator might notice a resident takes a medication
that causes dizziness or the service coordinator might see towels taped down as rugs on an
apartment floor during a visit. In each case, the team would work with the resident to try to
prevent a future fall. However, there is no systematic plan to address falls across the larger
resident population. If it is believed that this is a prevalent area of risk in the community, the
WellElder program might consider developing a more formal response that could include
Evaluation of the WellElder Program
56
implementing evidenced-based education and exercise programs, medication reviews and
periodic environmental checks in the common spaces and individual apartments.
Obviously responding to individual needs in times of crisis is key to helping residents resolve
their situations, but considering opportunities to address common needs more systemically might
allow for a broader reach across residents. In particular, more systematic prevention strategies
might increase the opportunity for the health educator to come into contact with more residents
and begin building relationships that will encourage residents to seek out the health educators
and follow their advice. Given the fact that the health educators noted during their interviews that
they do not have as strong of relationships with residents as the service coordinators and the
observation that resident focus group participants seemed less aware of how the health educators
could potentially assist them, a more proactive approach that addresses resident needs propertywide could increase the benefits of the WellElder program.
More Formal Approach to Helping with Transitions
One potential impact area for the WellElder program is around emergency department or
hospital discharges. Given the high levels of multiple co-morbidities and functional limitations
revealed in the resident self-assessment, residents may be at risk for overuse of the emergency
department or avoidable rehospitalizations. The program does not currently have a formal policy
for following residents in and out of the hospital. The WellElder nurse and service coordinators
attempt to engage with residents and their discharge planners when they are aware that they have
gone to the hospital. They acknowledge their potential role in helping to facilitate a smoother
transition from hospital to home, but also have identified several challenges in this area. Because
the building is an independent living property, staff is not always aware when a resident goes to
or returns from the hospital, and, when they are aware it, can sometimes be difficult to locate the
resident due to the multiple hospitals in the area. In addition, hospital staff may not be willing to
discuss anything about the resident with WellElder staff due to privacy laws.
Acknowledging these challenges, the WellElder program should consider developing a policy for
monitoring residents returning from an emergency room, hospital or rehabilitation facility stay.
This policy might consider mechanisms to help expand WellElder staff’s awareness of when
residents leave and return to the property, opportunities to increase awareness or communication
with hospital staff, and protocols for following-up with residents after their return. In the event
that health educators are not in the building for the first several days following a resident’s return
home, checking in with that individual soon after the transition has occurred can send a message
that the property acknowledges the difficulties surrounding such transitions and that the
WellElder team is available to help support the recovery process.
Clarification of Program Ownership and Authority
The research team observed a lack of clarity around who “owns” the WellElder program.
Although it is clear that various stakeholders are involved in the process, the program lacks clear
direction and authority. Although the program falls under the NCPHS Community Services
division, the division director also defers to the property managers and the IOA for program
policy and operation decisions. While incorporating input from interested parties is certainly
important for effective operations, the program would benefit from having a well-defined
structure for decision making.
Evaluation of the WellElder Program
57
Currently, property managers are given leeway to define how the program operates within their
property. While some flexibility may be needed to adapt to the specific circumstances of a
property (availability of health educator time, resident characteristics, etc.), these variations
should be defined by WellElder program leadership, not the property manager. The risk of
allowing individual property managers to change program activities is that the program may be
altered in a way that minimizes effectiveness. In one property operating the WellElder program,
the property manager has decided health educators are not going to engage in some activities that
are done in other properties (e.g., a prohibition against health educators conducting hospital
visits; non-completion of the annual emergency form and medication listing for residents
because of a similar process already in place in the property). If the WellElder program is to be
considered a team package across all properties, then their needs to be more consistency across
the sites to ensure optimal implementation and program success.
There also appears to be some ambiguity between the role of NCPHS and the IOA in defining
the health educator’s activities. When the health educators were asked who they consider their
“boss,” they said it was not always clear. One health educator mentioned that when they ask one
organization a question related to their role or activities, they often are told to ask the other
organization. The IOA is clearly responsible for clinically supervising the health educator and
monitoring what they can and cannot do within the scope of their nursing license. Outside of
those regulatory boundaries, however, the lines of authority appear to be a little more ambiguous.
Authority over the WellElder program is complicated by the different levels that fund and
supervise the WellElder staff. Service coordinators are funded by each property, but are
supervised under the community services division. Health educators are contracted by each
property from the IOA, but are clinically supervised by the IOA. These various stakeholders
certainly should have input into the policy and operations of the program. Property managers are
concerned about the health and wellbeing of their residents, and many tenancy-related issues for
which they are responsible are often interrelated with residents’ health and social needs. The
IOA is responsible for ensuring their nurses are providing quality services that are within the
scope of their professional boundaries. However, the program would benefit from having a clear
line of authority for consistency and oversight of program operations. While NPCHS will need to
consider this appropriate place within their organizational structure, the community services
division seems a logical location. This division already supervises the service coordinators. It is
also knowledgeable about the needs of aging seniors and has established relationships with the
community providers that may already be assisting residents or could become potential partners
of the WellElder program.
Co-location of the Health Educator and Service Coordinator in the San Jose Property
Unlike the other properties, the health educator and service coordinator in the San Jose property
are located on different floors. This physical separation potentially impedes greater collaboration
between the two roles. The distance hinders the ability to have impromptu joint meetings with a
resident when the need or opportunity arises. WellElder staff in the San Francisco properties note
that co-location allows them to quickly invite the other in when warranted and work jointly with
a resident. WellElder staff in San Jose reports that when one of them recommends that a resident
visit the other member of the team for further assistance, residents are sometimes unwilling to
Evaluation of the WellElder Program
58
walk to the other floor. One service coordinator noted that even she would sometimes just handle
something herself to save the phone call or trip to the health educator’s office. The San Jose
WellElder staff also note that the co-located San Francisco staff can start their day jointly
discussing emergencies or other resident situations or have impromptu conversations throughout
the day about resident needs. The San Jose staff believes they do not interact as much as they
might if they were located in closer proximity.
The health educators in the San Jose property noted that until recently it was not clear to them
that the WellElder program consisted of themselves and the service coordinators rather than just
the health educators. The physical separation between the two may have exacerbated the lack of
clarity about the WellElder program and the need for collaboration and integration of the two
positions’ skill sets. It also seems that the health educators in this property never received a
formal orientation on the WellElder program and their role, particularly with respect to their
collaboration with the service coordinator.
Eliminating the Membership Concept
Most residents participating in the focus groups were not familiar with the specific term
“WellElder Program” and were unaware they were program members. They were, however,
generally familiar with the service coordinator and health educator. The rationale for the program
being a membership program is not clear. There are no eligibility requirements to join the
program. Initially, it was perceived that residents might be more engaged in program activities if
they were called members. The enrollment forms (which vary slightly between the San Francisco
and San Jose properties) are primarily consent forms allowing WellElder staff to assist the
resident in obtaining needed assistance and releasing NCPHS from liability by any entities to
which residents are referred. The enrollment forms are signed in the presence of the health
educator, and residents sign additional/separate forms to receive assistance from the service
coordinator.
There is likely little value in making the program a “membership” plan. The program might be
better conceived as a service that is available to all residents and is an expression of the
property’s commitment to help residents meet their needs and maintain their health and quality
of life. Although it is not known whether this membership concept has inhibited participation,
one service coordinator noted that some residents do not like signing up for programs because
they are not sure what they are getting themselves into and do not want the hassle.
Concluding Remarks
In sum, the WellElder program is a relatively low-cost team approach to meeting the needs of a
range of residents in low-income housing properties. This study has provided important insights
into the program implementation and potential for resident impact. The participatory research
methodology employed during this study has helped the research team to formulate
recommendations that they believe will improve the program and increase the potential for
successful aging in place. The research team also believes that with the appropriate
modifications, the program will be ripe for replication.
Evaluation of the WellElder Program
59
References
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older adults: United States, 1993-2003 and 2001-2005. Morbidity and Mortality Weekly Report
(MMWR), 55(45), 1221-1224. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5545a1.htm.
Centers for Disease Control and Prevention. (2007). The state of aging and health in America.
Whitehouse Station, NJ: The Merck Company Foundation. Retrieved from:
http://www.cdc.gov/Aging/pdf/saha_2007.pdf.
Centers for Disease Control and Prevention. (2010). Vital and health statistics: summary health
statistics for U.S. adults: National Health Interview Survey, 2009. Series 10, No. 249.
Hyattsville, MD: U.S. Department of Health and Human Services.
Cho, Y., Lee, S., Arozullah, A. and Crittenden, K. (2008). Effects of health literacy on health
status and health service utilization amongst the elderly. Social Science and Medicine, 66, 18091816.
Cubanski, J., Huang, J., Damico, A., Jacobson, G. and Neuman, T. (2010). Medicare chartbook,
4th edition. Washington, DC: The Henry J. Kaiser Family Foundation.
Federal Interagency Forum on Aging Related Statistics. (2010). Older Americans 2010: Key
indicators of well-being. Hyattsville, MD: author.
Gazmararian, J. et al. (1999). Health literacy among Medicare enrollees in a managed care
organization. Journal of the American Medical Association, 281(6), 545-551.
Gibler, K. (2003). Aging subsidized housing residents: A growing problem in U.S. cities.
Journal of Real Estate Research, 25, 395-420.
Gu, Q., Dillon, C. and Burt, V. (2010). Prescription drug use continues to increase: U.S.
prescription drug data for 2007–2008. National Center for Health Statistics (NCHS) Data Brief,
No. 42. Retrieved from: http://www.cdc.gov/nchs/data/databriefs/db42.pdf.
Haley, B. and Gray, R. (2008). Section 202 Supportive Housing for the Elderly: Program Status
and Performance Measurement. Washington, DC: U.S. Department of Housing & Urban
Development.
Kochera, A. (2002). Developing appropriate rental housing for low-income older persons: A
survey of Section 202 and LIHTC property managers. Washington, DC: AARP Public Policy
Institute.
Evaluation of the WellElder Program
60
National Center for Heath Statistics. (2007). Early release of selected estimates based on data
from the January-March 2007 National Health Interview Survey, September 26 release.
Retrieved from: http://www.cdc.gov/nchs.
National Library of Medicine. (2010). Health Literacy. Retrieved from:
http://nnlm.gov/outreach/consumer/hlthlit.html.
Office of Disease Prevention and Promotion. Quick guide to health literacy. Washington, DC:
U.S. Department of Health and Human Services. Retrieved from:
http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf
Redfoot, D. and Kochera, A. (2004). Targeting services to those most at risk: Characteristics of
residents in federally subsidized housing. Journal of Housing for the Elderly, 18, 137-163.
Redford, L. and Cook, D. (Fall 2001). Rural health care in transition: The role of technology. The
Public Policy and Aging Report, National Academy on an Aging Society, Gerontogical Society of
America, 12(1).
Scott, T., Gazmararian, J,. Williams, M. and Baker, D. (2002). Health literacy and preventive
health care use among Medicare enrollees in a managed care organization, Medical Care, 40(5),
395-404.
Vogeli, C., Shields, A., Lee, T., Gibson, T., Marder, W., Weiss, K. and Blumenthal, D. (2007).
Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care
management, and costs. Journal of General Internal Medicine. 22(Suppl 3), 391–395.
Wilden, R. and Redfoot, D. (2002). Adding assisted living services to subsidized housing:
Serving frail older persons with low incomes. Washington, DC: American Association of Retired
Persons.
Evaluation of the WellElder Program
61
Appendix A: Group Education Sessions
Date
Topic
Provided By
Attendance
Property 1
October 2009
How Gender Roles Have Changed Since
1900s
Sexuality Educator
11
December 2009
Community Collage
SC & HE*
15
February 2010
New Year New Foods
SC & HE
24
April 2010
Spirituality and Sexuality
Sexuality Educator
6
April 2010
Gratitude and the Great Things about
Getting Older
SC & HE
17
May 2010
“Gotta Dance” movie presentation
SC & HE
9
May 2010
Nintendo Wii demonstration
SC & HE
12
September 2009
Importance of Touch
SC & HE
10
November 2009
Community Collage
SC & HE
10
January 2010
New Year New Foods
SC & HE
16
March 2010
Gratitude and the Great Things about
Getting Older
SC & HE
18
May 2010
“Gotta Dance” movie presentation
SC & HE
11
May 2010
Nintendo Wii demonstration
SC & HE
9
August 2009
Dental Health
Lifeways/OnLok
41
September 2009
Osteoporosis
Lifeways/OnLok
49
October 2009
Maintaining Your Brain
Lifeways/OnLok
40
October 2009
Flu/H1N1 Class
HE
33
November 2009
Arthritis
Lifeways/OnLok
25
February 2010
Common Questions About Diet and
Cancer: Part One
HE
41
September 2009
Importance of Touch
SC & HE
16
December 2009
Community Collage
SC & HE
15
January 2010
New Year New Foods
SC & HE
18
March 2010
Gratitude and the Great Things about
Getting Older
SC & HE
16
SC & HE
20
Property 2
Property 3
Property 4
May 2010
Nintendo Wii demonstration
*SC=Service Coordinator; HE=Health Educator
Evaluation of the WellElder Program
62
Appendix B: Resident Self-Administered Survey Results, by Membership
ABOUT YOU
1.
What is your age?
Member
n=294
Nonmember
n=104
Mean
78.7
74.5
Range
56-95
38-93
2.
.0005
What is your gender?
Member
N=297
Nonmember
N=105
Male
36.0% (107)
40.0% (42)
Female
64.0% (190)
60.0% (63)
3.
4.
P-value
.4824
Are you of Hispanic or Latino origin?
Member
N=269
Yes
P-value
8.2% (22)
Nonmember
N=94
11.7% (11)
P-value
.3033
What is your race? (check all that apply)
Member
N=294
White
Nonmember
N=105
P-value
36.1% (106)
29.1% (31)
.2342
Black or African American
2.0% (6)
3.8% (4)
.2955
Asian
57.7% (169)
58.1% (61)
1.0
Native Hawaiian or other Pacific Islander
0
1.0% (1)
.2632
American Indian or Alaska Native
.3% (1)
2.9% (3)
.0576
Other
3.1% (9)
1.0% (1)
.4658
5.
Were you born in the United States?
Member
N=294
Yes
6.
13.5% (40)
Nonmember
N=105
16.3% (17)
.5143
Is English your first language?
Member
N=295
Yes
P-value
14.2% (42)
Nonmember
N=104
19.2% (20)
Evaluation of the WellElder Program
P-value
.2700
63
7.
What is your current marital status?
Member
N=296
Nonmember
N=103
Married
39.9%(118)
47.6% (49)
Separated
4.7% (14)
4.9% (5)
Divorced
6.8% (20)
7.8% (8)
Widowed
37.5% (111)
28.2% (29)
Single
11.2% (33)
11.7% (12)
8.
Yes
Nonmember
N=104
62.4% (184)
53.8% (56)
P-value
.1317
Do you have any children? If YES, how many?
Member
N=256
Nonmember
N=85
Yes
256
85
Mean
2.9
2.7
Range
1-10
1-7
10.
.5126
Do you live alone?
Member
N=295
9.
P-value
P-value
.5503
How long have you lived in this apartment building?
Member
N=287
Nonmember
N=97
Mean
9.2
6.3
Range
.5-35
.5-30
P-value
<.0001
YOUR HEALTH
11.
In general, would you say your health is:
Member
N=290
Excellent
1.7% (5)
Nonmember
N=104
1.9% (2)
Very good
7.9% (23)
8.7% (9)
Good
16.9% (49)
23.1% (24)
Fair
50.7% (147)
48.1% (50)
Poor
22.8% (66)
18.3% (19)
Evaluation of the WellElder Program
P-value
.6304
64
12.
Because of a health or memory problem, do you have difficulty with any of the following
activities?
Member
Nonmember
P-value
Bathing/Showering
39.6% (111)
28.7% (28)
.0671
Dressing (pick out clothes, dress and undress
yourself)
27.0% (75)
22.7% (22)
.5008
Transferring from bed/chair/car
30.7% (85)
21.6% (21)
.1157
Using the toilet
23.4% (65)
18.6% (18)
.3943
Incontinence (wetting or soiling yourself)
25.3% (71)
26.0% (26)
.8942
Eating
21.6% (60)
15.3% (15)
.2391
Using the telephone
21.3% (60)
19.8% (19)
.8846
Shopping
51.4% (144)
38.0% (38)
.0265
Preparing meals
49.8% (138)
40.0% (40)
.1024
Housekeeping
61.9% (172)
43.0% (43)
.0014
Doing laundry
49.1% (135)
37.0% (37)
.0462
Traveling to places out of walking distance
54.3% (150)
40.6% (41)
.0201
Taking medications
27.0% (76)
22.5% (23)
.4291
Managing money or finances
21.0% (58)
20.8% (21)
1.000
Multiple ADLs
Member
Nonmember
P-value*
0
41.8% (116)
59.0% (59)
1+
58.2% (162)
41.0% (41)
.0019
2+
39.1% (109)
28.0% (28)
.0420
*Calculated using a logistic regression with those having less than the number of ADLs in the specified row as the reference
category
Multiple IADLs
Member
Nonmember
P-value*
0
24.3% (70)
35.9% (37)
1+
75.7% (218)
64.1% (66)
.0241
2+
69.1% (199)
46.6% (48)
<.0001
*Calculated using a logistic regression with those having less than the number of IADLs in the specified row as the reference
category
Evaluation of the WellElder Program
65
13.
Have you ever been told by a doctor that you have any of the following health conditions?
Member
Nonmember
P-value
High blood pressure or hypertension
68.0% (198)
64.7% (66)
.5422
Diabetes or high blood sugar
29.1% (84)
34.0% (35)
.0636
Cancer or a malignant tumor
9.8% (28)
8.9% (9)
1.000
Chronic lung disease
8.1% (23)
6.1% (6)
.6602
Heart problems
43.7% (124)
38.2% (39)
.3526
Emotional, nervous, or psychiatric problems
26.5% (75)
31.4% (32)
.3680
Memory-related disease
37.7% (107)
29.0% (29)
.1444
Arthritis or rheumatism
71.3% (206)
54.3% (57)
.0024
Parkinson’s disease
7.1% (20)
3.9% (4)
.3423
Multiple Health Conditions
Member
Nonmember
P-value
0
7.8% (23)
10.4% (11)
.1054
1+
92.2% (273)
89.6% (95)
.4093
2+
80.0% (237)
74.5% (79)
.2338
3+
57.0% (169)
48.1% (51)
.1117
4+
36.1% (107)
27.3% (29)
.1020
*Calculated using a logistic regression with those having less than the number of conditions in the specified row as the
reference category
14.
Have you ever had any of the following health events?
Member
Nonmember
P-value
Stroke
12.9% (35)
5.9% (6)
.0628
Hip fracture
13.4% (36)
6.9% (7)
.1013
Cataract surgery
43.7% (121)
42.3% (44)
.8177
15.
Are you often troubled with pain?
Member
N=292
Yes
78.1% (228)
Nonmember
N=103
64.1% (66)
Evaluation of the WellElder Program
P-value
.0083
66
16.
If YES, how bad is the pain most of the time?
Member
N=231
Nonmember
N=68
Mild
16.8% (39)
20.6% (14)
Moderate
59.7% (138)
57.4% (39)
Severe
23.4% (54)
22.1% (15)
17.
18.
34.2% (97)
Nonmember
N=101
24.8% (25)
Nonmember
N=24
Mean
1.9
1.7
Range
1-10
1-9
20.
Nonmember
N=102
20.7% (58)
17.6% (18)
Nonmember
N=18
Mean
1.9
1.8
Range
1-7
1-37
22.
.6790
P-value
.5642
P-value
.4874
During the past 12 months, have you had any outpatient surgeries?
Member
N=276
Yes
P-value
If YES, how many times have you been in the hospital overnight?
Member
N=57
21.
.0832
During the past 12 months, have you been a patient in the hospital overnight?
Member
N=280
Yes
P-value
If YES, how many times have you gone to a hospital emergency room?
Member
N=97
19.
.7790
During the past 12 months, have you gone to a hospital emergency room?
Member
N=284
Yes
P-value
Nonmember
N=98
26.0% (72)
24.5% (24)
P-value
.7894
If YES, how many times have you had an outpatient surgery?
Member
N=69
Nonmember
N=23
Mean
2.0
1.7
Range
1-12
1-12
Evaluation of the WellElder Program
P-value
.5478
67
23.
During the past 12 months, have you fallen down?
Member
N=277
Yes
24.
Nonmember
N=100
36.1% (100)
32.0% (32)
Nonmember
N=32
Mean
2.2
2.2
Range
1-10
1-10
Nonmember
N=95
Mean
6.2
5.2
Median
6
4
Range
0-19
0-21
Nonmember
N=84
Mean
2.4
1.8
Range
0-18
0-7
P-value
.0317
P-value
.0126
During the past 30 days, for about how many days have you felt sad, blue, or depressed?
Member
N=182
Nonmember
N=68
Mean
8.3
6.8
Range
0-30
0-30
28.
.9454
How many over-the-counter medications do you take?
Member
N=221
27.
P-value
How many prescription medications do you take?
Member
N=273
26.
.5411
If YES, how many times have you fallen down?
Member
N=100
25.
P-value
P-value
.2893
How many days during the past 30 days was your physical health not good?
Member
n=194
Nonmember
n=75
Mean
12.8
9.5
Range
0-30
0-30
P-value
.0314
SUPPORT NETWORK
29.
Do you have family, a significant other or friends in the area who can assist you when
needed?
Member
N=278
Yes
88.5% (246)
Nonmember
N=102
83.3% (85)
Evaluation of the WellElder Program
P-value
.2258
68
30.
How often does the family member, significant other or friend you have the most contact
with call you?
Member
N=274
Daily
50.4% (138)
Nonmember
N=103
45.6% (47)
Weekly
37.6% (103)
42.3% (44)
Monthly
5.5% (15)
2.9% (3)
Less than monthly
3.6% (10)
5.8% (6)
Family members never call
2.9% (8)
2.9% (3)
31.
.6045
How often does the family member, significant other or friend you have the most contact
with visit you?
Member
N=267
Nonmember
N=94
Daily
20.2% (54)
24.5% (23)
Weekly
49.4% (132)
45.7% (43)
Monthly
12.6% (33)
12.8% (12)
Less than monthly
10.9% (29)
14.9% (14)
Family members never visit
7.1% (19)
2.1% (2)
32.
P-value
P-value
.3031
How would you describe the level of assistance your family members, significant other or
friends provide you?
Member
N=270
Nonmember
N=101
Do not provide assistance
7.4% (20)
5.0% (5)
Limited assistance
28.5% (77)
26.0% (26)
Moderate assistance
23.7% (64)
21.0% (21)
Considerable assistance
32.6% (88)
30.0% (30)
I do not need assistance
7.8% (21)
19.0% (19)
Evaluation of the WellElder Program
P-value
.0659
69
SERVICE USE
33.
What types of services or activities do you typically use?
Member
% (number using
service)
Non-member
% (number using
service)
Unadjusted
P-value
Adjusted Odds
Ratio (95% CI)*
43.6% (122)
28.0 (28)
.0062
1.53 (0.87-2.69)
Homemaker services
71.7 (208)
46.2 (48)
<.0001
2.87 (1.44-5.73)
Meals programs
23.5 (64)
18.6 (19)
.4016
1.38 (0.74-2.56)
Assistance with medications
30.1 (84)
20.6 (21)
.0707
1.00 (0.53-1.89)
Personal care assistance
32.3 (91)
21.6 (22)
.0434
0.92 (0.45-1.85)
Adult Day Care
9.6 (25)
5.8 (6)
.3009
1.17 (0.40-3.42)
PACE
4.1 (10)
5.1 (5)
.7715
0.64 (0.17-2.38)
Exercise programs
27.5 (72)
16.0 (16)
.0279
1.83 (0.95-3.54)
Mental health counseling or therapy
18.8 (49)
15.2 (15)
.4451
1.17 (0.55-2.48)
Case management
6.7 (17)
1.1 (1)
.0313
NA
Bill paying assistance
13.8 (37)
17.0 (17)
.5074
0.45 (0.22-0.94)
Services
Transportation services
*Adjusted for property, age, presence of at least one ADL or IADL.
34.
Do you get services through MediCal?
Member
N=267
Yes
80.5% (215)
Nonmember
N=93
77.4% (72)
Evaluation of the WellElder Program
P
.5502
70
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