INSTITUTE ON AGING

COMMUNITY CARE PROGRAMS - SEE DESCRIPTION ON SCHEDULE O COMMUNITY CARE PROGRAMS INCLUDES LINKAGES/IOA CASE MANAGEMENT, COMMUNITY LIVING FUND (CLF), HOME SAFE, PG HOUSING, SAN MATEO HOME SAFE, SANTA CLARA CLC, AND ALL OF OUR CALAIM PROGRAMS: THESE ARE ALL CARE MANAGEMENT PROGRAMS WHICH PROVIDE ASSESSMENT AND COORDINATION OF SERVICES FOR ALL SORTS OF INDIVIDUALS WHO FIT AT LEAST ONE OF THE FOLLOWING CATEGORIES: DISABLED, HOMELESS, SERIOUS MENTAL ILLNESS, SUBSTANCE USE DISORDERS, SKILLED NURSING RESIDENTS, AT RISK OF INSTITUTIONALIZATION, OR THOSE IN NEED OF ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. THESE INDIVIDUALS LIVE IN SAN FRANCISCO, SAN MATEO, ALAMEDA, SANTA CLARA, RIVERSIDE, OR SAN BERNARDINO COUNTIES. SOME OF THESE INDIVIDUALS ARE IN NEED OF SHORT-TERM HELP WHICH MIGHT INCLUDE INSTALLING GRAB BARS, SHOPPING ASSISTANCE, OR INTERVENING IN AN EMERGENCY SITUATION. FUNDED IN PART BY THE DEPARTMENT OF AGING AND ADULT SERVICES, DEPARTMENT OF HEALTH CARE SERVICES, AND THE LOCAL MANAGED MEDICAL PLANS. THESE PROGRAMS ALL SEEK TO PROVIDE ACCESS TO NEEDED SERVICES TO ENABLE A PERSON TO CONTINUE LIVING INDEPENDENTLY.THROUGH THESE CARE MANAGEMENT PROGRAMS, A SOCIAL WORKER VISITS A CLIENT AT HOME AND WORKS WITH THE CLIENT TO DETERMINE WHAT SERVICES MIGHT BE HELPFUL. WITH THIS INFORMATION, A CARE PLAN IS DEVELOPED AND APPROPRIATE SERVICES ARE ARRANGED. THE SOCIAL WORKER CONTINUES TO STAY IN CLOSE TOUCH, WORKING WITH THE CLIENT TO ADJUST THE CARE PLAN AS NECESSARY. SOME OF THESE PROGRAMS HAVE ACCESS TO A WIDE ARRAY OF SERVICES, INCLUDING:-TRANSPORTATION-HOME SAFETY MODIFICATIONS-MEDICAL CARE-HOUSEKEEPING-LEGAL ASSISTANCE-SENIOR COMPANION-HOME-DELIVERED MEALS-MONEY MANAGEMENT-DAY ACTIVITY PROGRAMS-COUNSELING-GOVERNMENT BENEFITS. THE AVERAGE CASE LOAD FOR THE CASE PROGRAMS IS 25-40 CLIENTS. THE COMMUNITY LIVING FUND (CLF) AND SOME OF THE CALAIM PROGRAMS ASSIST WITH THE TRANSITION OF INDIVIDUALS WITH LIMITED INCOMES WHO HAVE SPENT YEARS LIVING IN HOSPITALS OR CARE FACILITIES AND WHO WISH TO RETURN TO LIVING IN THE COMMUNITY. CLF/CALAIM ALSO PROVIDES SERVICES TO INDIVIDUALS LIVING IN THE COMMUNITY WHO ARE AT IMMINENT RISK OF INSTITUTIONALIZATION. ALTHOUGH PATIENTS MAY WISH TO LIVE INDEPENDENTLY, AND HAVE THE RIGHT TO MAKE THAT CHOICE, THE TRANSITION FROM INSTITUTIONALIZED CARE TO INDEPENDENT LIVING CAN BE VERY DIFFICULT. PATIENTS FACE ORDINARY LIFE TASKS SUCH AS MEAL PREPARATION, BILL PAYING AND ORGANIZING MEDICAL CARE FOR THE FIRST TIME IN MANY YEARS. TO MAKE THIS TRANSITION SAFE AND POSSIBLE, CLF/CALAIM PROVIDES SERVICES FROM TRAINED PROFESSIONAL NURSES AND SOCIAL WORKERS. SOCIAL WORKERS AND NURSES PROVIDE SERVICE COORDINATION AND, WHEN NECESSARY, CLF/CALAIM CAN PURCHASE ITEMS AND/OR REFER TO COMMUNITY SUPPORT SERVICES TO MEET THE NEEDS OF AN INDIVIDUAL TO ENABLE INDEPENDENT LIVING.SAN FRANCISCO COUNTY ALSO SUPPORTS A NUMBER OF COMMUNITY BASED PROGRAMS WHICH PROVIDE EITHER CONSULTATIVE OR ASSESSMENT SERVICES FOR SAN FRANCISCO RESIDENTS. IN TERMS OF CONSULTATIVE SERVICES, THE DEPARTMENT OF DISABILITY AND AGING SERVICES FUNDS CITYWIDE/ADRC, ELDER ABUSE, FORENSIC CENTER, HIGH-RISK SELF NEGLECT, ELDER DEATH REVIEW, AND CLINICAL COLLABORATIVE SERVICES WHICH PROVIDE INDIVIDUALS OF VARIOUS SPECIALTIES INCLUDING NURSES, SOCIAL WORKERS, AND PROGRAM DEVELOPMENT SPECIALISTS WHO ALL SUPPORT PROGRAMS THAT ARE AVAILABLE TO CONSULT ON CASES OR CONCERNS THAT ARE PRESENT WITH INDIVIDUALS IN SAN FRANCISCO. ADDITIONALLY, THE DEPARTMENT OF DISABILITY AND AGING SERVICES FUNDS HOME DELIVERED MEALS, RESPITE CAREGIVER SUPPORT AND SUPPORT AT HOME WHICH ARE ALL ASSESSMENT SERVICES IN SAN FRANCISCO COUNTY WHERE OUR ASSESSMENT TEAMS DETERMINE THE CARE NEEDS OF INDIVIDUALS TO HELP CONNECT THEM TO NEEDED RESOURCES.THE DEPARTMENT OF HEALTH CARE SERVICES FUNDS A PROGRAM KNOWN AS HOME AND COMMUNITY BASED ALTERNATIVES IN WHICH A TEAM OF NURSES AND SOCIAL WORKERS PERFORM ASSESSMENTS AND CREATE PLAN OF TREATMENTS FOR INDIVIDUALS THAT ARE AT A SKILLED NURSING LEVEL OF CARE OF ALL AGES. WE CURRENTLY OFFER THESE SERVICES IN SAN BERNARDINO, RIVERSIDE, SAN FRANCISCO, AND SAN MATEO COUNTIES. IOA HAS MAINTAINED A FRIENDSHIP LINE PROGRAM WHICH HAS ALLOWED INDIVIDUALS TO USE A PHONE NUMBER TO CALL WHEN THEY ARE EXPERIENCING LONELINESS AND ISOLATION AND THIS PROGRAM WAS FUNDED PARTIALLY IN CALIFORNIA BY 3 DIFFERENT FUNDERS INCLUDING CALIFORNIA DEPARTMENT OF AGING, SAN MATEO COUNTY (MEASURE K), AND SANTA CLARA COUNTY. THIS IS A 24 HOUR CALL LINE WITH THE OPTION FOR FOLLOW UP CALLS TO ENSURE WELLNESS AND SUPPORT IS ACHIEVED.OUR CALAIM PROGRAMS WERE ALREADY MENTIONED, BUT IN MORE DETAIL THESE ARE CARE MANAGEMENT PROGRAMS WHICH ARE FUNDED BY THE LOCAL MANAGED MEDICAL PLANS. THERE ARE ENHANCED CARE MANAGEMENT AND COMMUNITY SUPPORT SERVICES WHICH PROVIDE SOCIAL WORKERS TO HELP INDIVIDUALS WITH ALL OF THEIR CARE NEEDS. A COMPLEX PSYCHOSOCIAL ASSESSMENT IS PERFORMED BY A SOCIAL WORKER TO CREATE A COMPREHENSIVE CARE PLAN WHICH IS THEN USED AS THE FRAMEWORK TO DIRECT OUR TEAMS CARE DELIVERY. SOME CLIENTS ARE IN NEED OF COMMUNITY SUPPORT SERVICES WHICH PROVIDES HOUSING NAVIGATION, HOUSING TRANSITION, TENANCY AND RETAINING SERVICES AS WELL AS MANY MORE. WE OFFER THESE SERVICES IN SAN FRANCISCO, SAN MATEO, SANTA CLARA, ALAMEDA, RIVERSIDE, SAN BERNARDINO, WITH NEW COUNTIES ON THE WAY. IN SANTA CLARA SPECIFICALLY, WE ALSO CREATED A NEW PROGRAM WHICH DEVELOPED A NETWORK OF RESIDENTICAL CARE FACILITIES TO ALLOW FOR OPTIONS FOR HOUSING WHEN INDIVIDUALS HAVE BEEN IDENTIFIED AS APPROPRIATE TO LIVE INDEPENDENTALLY IN THE COMMUNITY. ADDITIONALLY, IN ORDER TO LAUNCH NEW GEOGRAPHIES, DHCS HAS PROVIDED FUNDING THROUGH A GRANT KNOWN AS PATH WHICH WE WERE AWARDED TO SUPPORT OUR OPERATIONS (STAFF) AND SYSTEMS (ELECTRONIC MEDICAL RECORD AND DATA INTEGRATION).

ALL-INCLUSIVE MEDICAL CARE (PACE) - SEE DESCRIPTION ON SCHEDULE O ALL-INCLUSIVE MEDICAL CARE (PACE) - IOA OFFERS ON LOK'S PROGRAM OF ALL INCLUSIVE CARE FOR ELDERLY (PACE) ADULTS OVER 55. THIS IS A CUSTOM CARE PLAN DESIGNED FOR EACH PERSON BASED ON THEIR SPECIFIC NEEDS. INDIVIDUALS RECEIVE THE FOLLOWING BENEFITS:-PHYSICAL, OCCUPATIONAL, SPEECH, AND RECREATIONAL THERAPIES-HOME HEALTH CARE AND PERSONAL CARE-NUTRITION SERVICES AND HOME DELIVERED MEALS WHEN NEEDED-TRANSPORTATION AND EMERGENCY MEDICAL TRANSPORT-SOCIAL SERVICES-PRIMARY MEDICAL AND SPECIALTY CARE AS NEEDED (SUCH AS CARDIOLOGY, NEUROLOGY)-ROUTINE PREVENTATIVE CARE SUCH AS AUDIOLOGY, DENTISTRY, OPTOMETRY, AND PODIATRY-NURSING CARE AND MONITORING-ADULT DAY HEALTH CARE-PRESCRIPTION DRUGS-ACUTE HOSPITAL AND NURSING HOME CAREIOA'S PROFESSIONAL STAFF INCLUDE PHYSICIANS, DENTISTS, SOCIAL WORKERS, PHYSICAL AND OCCUPATIONAL THERAPISTS. THIS FULLY INTEGRATED, ALL-INCLUSIVE PROGRAM ENABLES PEOPLE TO HAVE MANY SERVICES UNDER ONE UMBRELLA. IN ADDITION TO MEDICAL CARE, INDIVIDUALS ENGAGE IN VARIOUS SOCIAL ACTIVITIES, EXERCISE AND RECEIVE NUTRITIOUS MEALS WHILE ONSITE.