Spotlight on Innovations and Achievements: Senior Services of Southeastern Virginia

• By: USAging
• On: 11/08/2019 08:25:27
• In: Hot Topics in Aging

The Health Empowerment Program (HEP) is the result of a three-way partnership between Eastern Virginia Medical School's Department of Family Medicine, Sentara Healthcare's primary care practices and Senior Services of Southeastern Virginia. With the goal of improving care for older adults identified as high-risk/high-need during Medicare annual wellness visits, health coaches conduct in-home visits and provide assessment and educational services to this population.
 
After the initial home visit, the health coaches follow up at 30 and 60 days to assess how well patients are addressing the issues identified during the first home visit. SSSEVA reports that all participants who completed the program showed an increase in confidence levels regarding understanding and taking medications correctly, knowing their red flags, and the lifestyle changes needed to address their medical issues. Participants also voiced satisfaction with the program. Both accomplishments are extremely important as they predict better adherence to care plans and patient buy-in, which leads to better health outcomes.
 
Though it was a small pilot program, HEP demonstrated how the integration of health care with community-based organizations can positively impact population health by providing education and linkages to services that address the social determinants of health. Given the ever-growing number of older adults who are in need of information, referrals and services that can allow them to remain safely in their homes, the SSSEVA team deemed the program a success.
 
One caregiver was particularly impressed with the collaboration between her mother's primary care doctor, his staff and the coach from SSSEVA, as well as with the actual services that the coach was able to put in place that helped ease her caregiver burden. Eventually, her mother was linked to a visiting physician's program when she entered hospice and was bed-bound, thus highlighting the importance of good transitions of care across the spectrum that are based on the client's changing needs.
 
To learn more about Senior Services of Southeastern Virginia's Health Empowerment Program, contact Brad Lazernick, Director of The Center for Aging and Interim Wellness Director at blazernick@ssseva.org.

Want to learn more about the 2019 AIA Innovations winners? REGISTER NOW for our four-part webinar series, n4a Lunchtime Innovations, to hear your peers' secrets to success for these award-winning programs.
 
For more information about the 2019 winners, read our press release and check out our book of winners to learn how your agency can implement this or similar programs in your community!