Atlanta Habitat for Humanity and National Church Residences are partnering to offer additional services to Habitat’s Repair with Kindness program participants who are age 55 or older. These benefits can help them live independently and stay in their homes for life. The Repair with Kindness program helps qualified homeowners make critical home repairs that reduce health or safety hazards or improve weatherization for residents.
A National Church Residences Service Coordinator meets with homeowners identified by Habitat for Humanity and uses Care Guide to assess the needs of community seniors. This program is a great addition to what National Church Residences is doing in the building in Atlanta. This program enables us to reach those who may not live in our buildings but need help identifying services.
Many seniors prematurely enter nursing facilities because they are unaware of the services that are available to them or they have no one to assist them. Our Service Coordinator visits these residents in their homes and helps determine what each person needs. Recognizing that every person is unique, the Service Coordinator takes time to get to know the resident’s health and social needs. They then can arrange a variety of services, including Home Health, Legal Aid Referrals, Budgeting and Financial Literacy training, Emotion Support and more.
This partnership with Atlanta Habitat for Humanity allows us to extend our reach in the Greater Atlanta and surrounding communities, helping us to continue with our mission to enable seniors to stay home for life.
GREELEY, Colorado – Bonnie Dietz and her friends often gather in the lounge at Birchwood Apartments to play cards.
One afternoon nearly three months ago, Jane Schwarz, the building’s National Church Residences Service Coordinator, stopped by the group to check in.
“The lounge is right outside of Jane’s office,” Bonnie said. “She came out and talked to me for a minute and she said, ‘when you get finished with your card game, I want to talk to you.’”
Jane had a question for Bonnie that, at the time, seemed odd. However, it turned out to be a question that may have saved Bonnie’s life.
“Out of the blue she said, ‘have you seen a urologist?’” Bonnie said. “I thought, what’s going on? I have had a bit of kidney problems along with my diabetes. I didn’t know Jane was interested in this. I knew she knew about it. But I puzzled over it for a while. I thought it must just be something she needs to know.”
What Jane was doing was utilizing Care Guide, National Church Residences’ innovative program designed to create better long-term health care outcomes for our residents.
“Sometimes I pull up Care Guide and just look at what I wrote last quarter and I ask residents if they’re still going through the same things. I ask them, ‘are you still doing this or that?’ Or ‘are you still on the same amounts of this medication?’ Or just, ‘how are you feeling?’” Jane said. “Then sometimes they start telling you more about other things.”
Because of Jane’s question, Bonnie decided it might be time for a visit to her primary care physician for a check-up.
“It did instigate me to call and make an appointment,” Bonnie said. “I went in to see him on Feb. 1. He said my diabetes is fine and my blood pressure is fine. They took some lab work. Then he called the next day and said get over to the nephrology clinic because you’ve got some problems.”
Bonnie went to see the nephrologist – a doctor that specializes in kidney care – and found out some shocking news.
“I went over there and they tested my kidneys,” she said. “They said I was down to 30 percent of my function. Anything below that and you have to start thinking about dialysis.”
Shortly after hearing this diagnosis, Bonnie made an appointment with Jane to help her figure out Colorado’s Food Tax Rebate paperwork.
“I thought I was in trouble. She said, ‘first, I want to talk to you,’” Jane said. “She asked me why I had asked her about kidney disease. I explained that it was one of the chronic conditions that we follow up on in Care Guide.”
“I didn’t know that the Service Coordinator did that,” Bonnie said. “She was so tickled that her question had spurred me to go and see the doctor.”
Bonnie’s primary care physician gave her some recommendations on how to help strengthen her kidneys and avoid having to start dialysis.
Bonnie, who is 83 years old, has lived in a few different senior citizen apartment complexes.
“I was a cook in hospitals and nursing homes when I lived in Kansas,” she said. “Before that we were farmers. We had a farm and raised a family here (in Colorado).”
After her husband of 33 years passed away, Bonnie chose to move into an apartment. It wasn’t until she arrived at Birchwood Apartments, however, that she was introduced to a Service Coordinator.
“It’s really helpful,” she said. “There’s so much paperwork and things anymore that she can help me with. I don’t have a car and have to find transportation. It really is a help to have her here. She provides workshops during the week for different things. Right now there’s a living healthy workshop that comes once a week and we go attend that. It’s a real help.”
Jane said that as a National Church Residences Service Coordinator, it was exciting to see the work she does pay off in such a direct way.
“Sometimes it’s hard to see an action when you’re helping somebody because you don’t see the reaction,” she said. “In this case I did and I saw it come full-circle. It was exciting for me to see that take shape.”
Birchwood Apartments is a 173-resident senior apartment complex that has a Service Coordination contract with National Church Residences. Jane said that when Care Guide was first introduced, residents initially had some questions. But today they full embrace the positive impact it has had on their overall health.
“Just having the discussions with them prompts them to think about their health and more forward and talk to their doctor about it,” Jane said. “Bonnie is really good about advocating for herself and she took some action.”
The role of service coordinators is changing as they become more proactive in linking residents and clients to the services they need to age in their homes. It’s not easy to track the needs of dozens or even hundreds of residents, so National Church Residences now has a new tool to help the service coordinators with this important job.
National Church Residences Service Coordinators:
Help residents to Age in Place in their home
Link residents to services to help them remain independent
Provide cost savings to the resident, property management companies, and the government
Benefit entitlement education
Reduce apartment turnover
Reduce unnecessary hospital visits, 911 calls, and ER visits.
Reduce rehospitalizations and premature moving to higher levels of care.
This year, National Church Residences has launched a new online documentation system that allows our Service Coordinators to track the health and livelihood of their residents, in turn catching potential risk factors earlier that could result in less unnecessary hospital visits, a reduction in premature moving to higher levels of care and overall increase in resident’s quality of life.
This new documentation system, called Care Guide, was rolled out to 14 National Church Residences pilot communities in May and then following our National Conference in October the rest of Ohio was trained. By the end of the year, every National Church Residences Service Coordinator at our owned or managed properties will be trained to use Care Guide.
“This is a new way of empowering and guiding the Service Coordinators to be proactive in their work,” said Michelle Missler, Director of Supportive Services for National Church Residences Home & Community Services.
Michelle started her career with National Church Residences in 2003 as a Service Coordinator at Stafford Court and Village in Worthington, Ohio. “I remember sitting in my office at Stafford and I would wait for residents to come to me with needs. I never sought out a resident. This is the mentality of Service Coordination across the board and Care Guide is going to change that.”
National Church Residences Service Coordinators work in communities across the nation that house a large population of dually eligible vulnerable residents, people who receive both Medicare and Medicaid. This population is costing insurance companies a lot of money because of unnecessary 911 calls, rehospitalizations, and ER visits.
The Affordable Care Act penalizes hospitals when a person is readmitted for the same issue in less than 30 days. Care Guide arms the Service Coordinators with tools that allow them to be proactive. These tools include a Vulnerable Elderly Scale, Mini-Mental Status Exam, and a Geriatric Depression Scale. These tools help identify the highest-need residents who are most likely to end up traveling in and out of the hospital.
“With the addition of this new, proactive approach for providing services to our residents, we will be able to get ahead of a crisis. Service Coordinators are fantastic at linking residents to great resources when the issue is presented to the Service Coordinator imagine a world where we will get ahead of a crisis and in turn prevent those stressful events in our residents’ lives. That is the goal of this new approach to Service Coordination. We want to help prevent these crises and make the lives of our residents happier, healthier and less stressful,” Michelle said.
In addition to those tools, a reporting function allows Service Coordinators to share the findings, showing the impact of the program. National Church Residences has hired a report analyst to categorize and group data into readable information.
“As we begin to gather data from Care Guide, we will be better equipped to tell the success and impact of the Service Coordinator program. We will be able to see exactly what interactions help a resident to age in place successfully. The outcomes will show us where we can work to improve the care for our residents and pinpoint those interventions that help save lives and money. Service Coordination has always made a difference in the lives of our residents; we will now be able to show the impact in many different ways to many different audiences,” Michelle said.