Thriving (Aging) In Place Services for Older Adults

Approximately 40% of the people LifeSTEPS serves are older adults. Our primary emphasis is to help these residents age-in-place for as long as possible.

There are multiple benefits that accompany Thriving (Aging) in-Place. First, older adults experience independence, freedom and autonomy.

Along with this independence, they belong to vibrant communities that feature community events and socials. Combined, these benefits help older adults to fend off depression, which is often a result from isolation and a feeling of helplessness. LifeSTEPS supports Thriving (Aging) In Place by providing these services:

• Case management (includes assistance with applying for Medicare/Medi-Cal; In Home Help Assessments and referrals; Fall Prevention Assessments and Home Modifications Recommendations); Chronic Disease Management
• Emergency assistance (crisis intervention)
• Education programs (includes health and wellness, financial education, physical activity)
• Social programs/events/celebrations
• Food/nutrition programs

In addition to providing appropriate direct services, the LifeSTEPS social worker (resident services coordinator) also makes connections with other service providers in their community, helping to identify appropriate service providers, assisting residents in making contact, and following up to monitor progress.  LifeSTEPS partners with local Senior Centers and Area Agencies on Aging to access aging network services for our clients.

Special Emphasis: Older Adults that are Trapped-in-the-Gap

A significant issue that potentially prevents older adults from Thriving (Aging) In Place is a condition of being “trapped in the gap”. These are individuals with a monthly income that is slightly too high to qualify for all Medi-Cal benefits without a share of cost (especially in-home health services), but do not make enough to pay for the out-of-pocket expenses associated with the appropriate care they will need. Trapped in the Gap older adults are not eligible for services that Medi-Cal beneficiaries receive, including In Home Supportive Services, incontinent supplies, Durable Medical Equipment, Transportation, and Adult Day Health Care. Unfortunately, this population of residents must often make difficult choices like, “do I pay for prescriptions or an in-home caregiver one day a week, or do I buy groceries, or even pay my rent?”.

As their need for in-home health services increases, the likelihood they must prematurely enter a skilled nursing facility (SNF) also increases. According to the California Department of Health Services, 11.4% of those living in skilled care facilities do not need to be there. The effects of entering skilled nursing prematurely have devastating effects on the individual, their community, and California as a whole.

The Effect of Being Trapped-in-the-Gap can be Devastating

For the individual, premature entry into an SNF will likely reduce their life expectancy by 50% (Journal of the Academy of Life Underwriting 2009). Losing independence and autonomy, along with the potential that other family members do not live close by, creates isolation and eventually depression for many adults. When the individual is removed from their community, their friends and neighbors are also affected – feeling a sense of loss and mourning. There is suddenly a hole that can never be re-filled.

Premature entry also has a negative impact on taxpayers. Generally, a skilled care facility will cost $300-600 per day – which is typically 2-3 times what it would cost to live independently. As the population of older adults increases (it is estimated that seniors will comprise 20% of the overall population by 2020), this financial impact will become much more significant.

With our focus on Thriving (Aging) In Place, LifeSTEPS has taken the “trapped in the gap” issue head-on. Because we have direct contact with the population affected by this condition, we’ve developed a special empathy for their situation, and, guided by our mission, have made a commitment to affect change for the individual and in the community.  LifeSTEPS is proud to be a member agency of the California Collaborative for Long Term Services and Supports https://www.ccltss.org/, as well as the representative on the LeadingAge Public Policy Committee.

Keeping Residents Housed is LifeSTEPS’ Priority

In addition to our standard level of age-in-place services for older adults, we also take a few extra steps in serving those who are “trapped in the gap”.

• Provide a higher level of case management, especially in finding service providers and making referrals
• Work closely with the resident to analyze income to identify possible means of lowering their countable income to meet the income threshold (Often many who are “trapped in the gap” may earn just a few dollars too much. Were they to purchase a small vision or dental policy, their income would be reduced and they may qualify for Medi-Cal benefits without a share of cost).
• Advocate for the resident directly with government agencies and others that could help meet the resident’s needs.
• Advocate for policy change that would better serve this growing population of older adults.

For more information on the “Trapped in the Gap” issue, please download our special report: Trapped In The Gap