Over the past several years Jewish Family Services has established several programs to help older adults in the Jewish community maintain their independence. Now JFS is changing the scope, focus and name of the Jewish Senior Network — a program established by the Jewish Federation in 2001 which assists Jewish older adults and those with disabilities to live with dignity and autonomy in their own homes and communities — to better serve the needs of seniors in the community.
JSN, which has been run by JFS for the past several years and serves approximately 350 individuals, will now be called Care Management. Its main mission will continue to be to help older adults live in their own homes with as much independence as possible. Professional care managers, who will be social workers trained in working with senior adults, will help Care Management clients navigate the challenges of aging by providing connections to support and resources. Another goal of the revised program is to reduce admission to more acute levels of care including hospitals, assisted living facilities and skilled nursing facilities.
“Care Management will now be a core part of all those other services. In a lot of ways it’s a thread to help connect you from one program to another,” said Don Goldman, JFS executive director and CEO.
“Maybe you’re in one program such as JET Express or Help@Home and you think you need another as well. Or you are in one of our other programs and you’re having trouble thriving. Now we have a program to help you figure out if there is a program inside or outside JFS that you need to access.”
“If it turns out home is not the right answer for them, we help them with the transition as well,” Goldman continued.
As early as the end of this week, current JSN participants will receive a letter explaining the name change and alterations in services. Two of the most noticeable changes will be an increased number of care managers and a change in the way financial subsidies are doled out.
In January of this year, JFS piloted a new program by the same name. The pilot was led by Laura Gilman, who holds a master’s degree in social work and worked in both hospice and hospital settings before joining JFS.
“The pilot program, funded by the Gould Charitable Foundation, was for older adults outside the Jewish community who were struggling to navigate the challenges of aging,” Goldman said.
“The trial really was both to expand our services beyond the Jewish community in that area and also to investigate a modern, up-to-date outcome-based program because the JSN program was developed 13-14 years ago and needed some updating,” Goldman continued.
Goldman said the two programs — the trial program for the general community and the program for the Jewish community — will be merged and use the same staff. However they continue to be funded separately. The Jewish program will be funded by Jewish Heritage Foundation, Jewish Federation of Greater Kansas City, Menorah Legacy Foundation and Jewish Community Foundation.
Beefing up the program
Richard Odiam, LCSW, LSCSW, JFS director of clinical services, said the old JSN was more of a crisis management service because it was so large relative to the amount of staff assigned to it. Since 2007 JSN grew from approximately 150 clients to more than 350 clients now.
While the number of participants grew, the staffing for the program did not. Clients were receiving assistance, but their care was not being efficiently managed. For example, Goldman explained that in most cases a care manager was not able to figure out if the money being spent by JSN on a client was being spent on things the client actually needed to live independently.
“So the type of support that Laura has been able to give to those in the pilot program is much more ongoing and effective. She’s visiting them often, checking in with them, getting them resources and following up to make sure the resources are being taken advantage of. On the JSN side, we haven’t had staffing to do that and that’s what we want to do now,” Goldman said.
Implementing the change
Odiam said the next year will be a transition year for Care Management. Right now there are only 1.5 full-time equivalent staff members assigned to the program, meaning the care manager to patient ratio is about 1 to 200.
“Our reach has been broad but not very deep. We are looking at changing that with a deeper and more strategic engagement with the clients that we work with,” Odiam explained.
JFS plans to hire three additional care workers, two at the beginning of the year and one toward the end of 2014 or early 2015. That should make the case load more manageable with one care manager for every 50 clients.
“The intention is for care managers to be much more actively engaged with clients and be able to do more comprehensive assessments and develop more strategic plans to help them with the support and resources needed to live at home for as long as possible,” Odiam said.
Throughout 2014, care managers will meet with every one of its JSN clients to better assess their situation and transition them into the new Care Management program.
“We’re going to start with the most complex situations first,” Odiam said.
“We think these people can really use the support we haven’t been able to provide and we want to evaluate to see if they are in the right situation and how we can help,” Goldman added
Odiam explained that a care worker will complete a psychosocial and financial assessment of the client, and then initiate a service plan based on the client’s goals. He estimates services will be provided for three to six months to make sure supports are in place and goals planned together are achieved.
“Then we will taper off our services,” he said.
The pilot program using this model has been well accepted. Odiam reports that clients have reported the care management services have helped them navigate the complicated Medicaid system, reduce worry over their health and increase their ability to manage healthcare needs.
Reduced reliance on subsidies
A big change in the program will be how JFS provides financial assistance to Care Management clients. Up until now clients have been reimbursed for a portion of eligible medical expenses.
“This has grown a lot and become very expensive. It’s also a really passive system in the sense that it’s not something that’s planned together with a care manager around addressing specific needs,” Odiam said.
“We will still have financial assistance available through the program but now we will be much more individualized and targeted to leverage a particular outcome for a client,” he continued.
Explaining further, Odiam said that money can be given for something like shoe orthotics or a large ticket item such as a chair stair life that can help a client continue to live in a two-story home.
Care managers will also know where to find other subsidies, such as public entitlements or community resources, for clients.
“For example we will help someone get Medicaid services, which is not easy to navigate even for our care managers and just make sure they get all the forms and all the information they need and know what to do to re-up and stay active,” he explained.
JFS is also planning to add a volunteer component to the program.
“The role of volunteers will be critical. One area in which they can be helpful is that it can be really difficult for case managers to back out of a client’s life because often clients are really isolated and lonely. Having the option to have a friendly visitor engage with the client frees the case manager up to focus their efforts on another client,” Odiam said.
Goldman added that a trained friendly visitor volunteer still provides JFS with someone who can keep an eye out on the client if other needs arise, at which time the care manager will step back in to re-assess the situation.
“It they are a Help@Home member or a JET Express member, we also have a link to them. We try to create multiple ways to reach out and have links to clients that don’t need intensive support from our care managers,” Goldman said.
Right now Care Management is a completely free program. Plans call for that to change down the road as well, most likely sometime in late 2014 or early 2015.
“There are people who have means and as we raise the level of service we will move this to the same model of our other services, which means the services will be provided on a sliding scale. That means the people who do have means will get the same great service and they will help support the program,” Goldman said.
Goldman said the JSN program with 350 clients is larger than another program of its kind “that we know of” in the Kansas City community.
“It’s an area where the Jewish community is ahead of the curve,” Goldman said.
