Aging in Shelter Collaborative

Background/Scope of Project:

The Aging in Shelters Collaborative (ASC) launched by WoM in 2010, involved seven cooperating organizations and focused on some of the most medically needy and least connected elderly homeless women in Boston. The ASC program successfully connected 103 women, aged 55 and older, with primary care providers (PCPs), facilitated safe and stable housing, engaged volunteer health care companions to accompany women to appointments, and by working with multiple agency collaborators, found long-term supports to achieve better access to services and improve the health and health literacy of these women.  The ASC framework was built on frequent face-to-face contact supplemented by an integrated communication hub with a specially-designated ASC nurse in the middle as caregiver, case manager, patient educator and navigator.

Highlights of the Final Results:

• Developed a team of volunteer patient navigators— Up to 10 individuals volunteered as Health Care Companions (HCCs) and accompanied clients to nearly 60 appointments
• Initiated a virtual community of primary care practitioners (PCPs)– WoM developed a list of 25 Boston area PCPs who were willing and able to accept any of our participants into their practices or for urgent care on 48 hours notice
• Percent of participants who maintained stable housing: 82% total and 73% within first year.
• Percent of participants with chronic illness who saw their PCP at least twice per year: 32% in first year and over 70% by the end of second year.
• Number of participants with Psych issues that met with the Psychiatrist: 30.
• Percent of participants with diabetes who maintained blood sugar control: 70%.
• Percent of ER visits prevented: WoM tracked ‘milestone events’ or health behaviors and documented an average of 6 ‘prevented ER visits’ per week during the grant period.