New York State Office of Mental Health’s “Partnership to Support Aging in Place in Communities Severely Impacted by COVID-19” (PSAP).
The latest Geriatric Mental Health Act service demonstration grants, the Partnership to Support Aging in Place in Communities Severely Impacted by COVID-19 (PSAP), targets the ongoing negative impact caused by the COVID-19 pandemic on the mental, behavioral, and physical wellbeing of older adults. All projects aim to support older adults aged 55 years and older withaging in the communities of their choosing. These individuals may be unconnected or inconsistently connected to the system of care, have diagnosed, un/under diagnosed, or subacute behavioral issues, with a majority having co-occurring, chronic medical conditions.
The PSAP program model requires the development of a triple partnership between a New York State (NYS) Office of Mental Health (OMH) licensed provider, a NYS Office of Addiction Services and Supports (OASAS) provider, and a local Area Agency on Aging (AAA).
1. Central Nassau Guidance & Counseling Services, Link-Age
The Link-Age Program is a triple partnership between the Nassau County Office for the Aging, Family & Children’s Association (FCA), and Central Nassau Guidance & Counseling Services (CNG). Link-Age aims to pre-empt and address the isolation of older adults 55+ living in the community of Nassau County whose independence, tenure or survival in the community is in jeopardy because of their behavioral health concerns. The program assists with challenges related to aging, difficulty connecting with services, and addresses access and connection to medical care. The program provides referrals to long term care resources and support, improving the safety and overall quality of life of older adults. Link-Age offers a blend of in-person and telehealth support to the client, technology education, short term counseling, case management, peer support, and health education. A Certified Recovery Peer Advocate (CRPA) offers substance use education and recovery maintenance services, while clinicians and social workers provide individual mental health counseling and complex case management. A registered nurse attends to medically related needs, offers health advocacy and education. The Link-Age Program implements a person-centered, trauma-informed, and culturally responsive approach to the clientele they serve. Program staff work to accomplish this through individualizing approaches for each client, serving a myriad of racial, ethnic, and cultural identities, and responding with care and compassion to each case.
2. Orange County Department of Mental Health, EWOGI
The Enhanced Welcome Orange Geriatric Initiative (EWOGI) includes several local agencies that provide specific expertise. All partners can access clients’ Electronic Health Records to streamline coordination of care. The project serves those who have been traditionally underserved through increasing stabilization in the community and reducing avoidable emergency department, hospital, and nursing home admissions. EWOGI matches individuals with services and supports based on their unique needs, supporting older adults to improve their wellbeing, and leveraging technology to better serve the population. Services are provided both in the community and in clients’ homes for those with mobility or transportation challenges. The Orange County Department of Mental Health collaborates with substance use provider Catholic Charities of the Hudson Valley, and the Orange County Office for the Aging to provide holistic, integrated services. The triple partnership utilizes the Mental Health Association of Orange County as a gatekeeper organization that facilitates client matching with a range of partner agencies based on their needs. Community partners include Independent Living Inc. for peer services and personalized supports promoting independence; Jewish Family Service of Orange County for friendly visiting, counseling, and transportation; Rehabilitation Support Services providing medication management; and Orange County Adult Protective Services.
NYC Based PSAP Sites
3. Commonpoint, MIST
Maintaining Independence and Safety through Technology (MIST) engages older adults with screenings in clients’ homes or communities and, based on their personally assessed behavioral health, physical health, and aging service needs, connects clients with needed services and technology to reduce social isolation and loneliness. In some cases, this means purchasing new laptops or computers for clients who cannot afford them, and in all cases, it means teaching the individuals how to use their technology, whether it is a new purchase or something they already own, such as a smart phone. An individualized plan of care is created for each client, including a home safety assessment, with clinical social workers, a registered nurse, and Certified Peers. Mental health clinic services are provided by Commonpoint’s CAPE MHOTRS (Mental Health Outpatient Treatment and Rehabilitative Services) program. Rego Park Counseling accepts substance use warm hand-off referrals for treatment, and a NYC Aging consultant provides personalized support in connecting individuals to needed aging services. MIST offers intensive transitional care coordination, only discharging clients when they are bridged to longer term services and supports to address all their holistic needs. MIST addresses unmet needs through connecting clients with products that maximize independence such as blood pressure monitors, large print calendars, medication reminders, emergency alert buttons, hearing amplifiers, and hallway nightlights to reduce the risk of falls.
4. Jamaica Hospital Medical Center, SAIL
The Successful Aging for Increased Longevity (SAIL) project mission is to decrease un/under-treated mental health and substance use disorders among at-risk individuals living in the Jamaica, Queens community. Jamaica Hospital Medical Center partners with Flushing Hospital Medical Center and NYC Aging to provide culturally attuned, on-site mental health, substance use, and aging services in the client’s preferred language. SAIL aims to decrease avoidable episodic care in the emergency department as well as maladaptive behaviors that contribute to poor mental and physical health. SAIL also implements a twelve-week Fitbit program for older adults with embedded curriculum developed by NYC Aging that focuses on both physical and mental health including ongoing discussion and support in a group setting. Participants have the option to stay enrolled in the Fitbit program for an additional six weeks. To continue permitting older individuals to successfully age at home in their preferred community, SAIL provides resources for necessary items such as bedrails, blood pressure monitors, and gift cards to address food insecurity.
5. Ohel Children’s and Family Home, LACES
The mission of Ohel’s Linking Aging and Community with Everyday Services (LACES) program is to connect older adults with a full array of services so that they can successfully age in the place of their choosing. The LACES multi-disciplinary team conducts outreach, engagement, field-based screenings, and assessments in clients’ homes and throughout the Far Rockaways, a community that is geographically isolated from many service providers. LACES maintains an on-site presence within the Far Rockway communities at Older Adult Centers, health fairs, and cultural events, connecting older adults to evidence-based mental health, substance use, and aging services right in Far Rockaway through its triple partnership of Ohel, LSA Recovery, and NYC Aging. Using a person-centered approach, LACES connects individuals to physical health supports outside the Rockaways, when necessary, personalized assistance when applying for benefits, and a wide range of technology, including Artificial Intelligence robot companions, virtual assistants, and durable medical equipment not covered by insurance to promote independence and wellbeing while reducing loneliness.
6. Service Program for Older People, STRIVE
The Service Program for Older People (SPOP) Support, Treatment, Recovery, Independence, Voice, Education (STRIVE) program supports aging in community settings by offering person-centered services to reduce premature institutionalization of older adults. STRIVE offers integrated services related to overall health and psychological well-being and connecting clientsto socialization opportunities and community-based programs. STRIVE addresses concrete needs through intensive case management services and easy access to mental health clinical treatmentcomplemented by the support of an OMH Certified Peer Specialist. STRIVE employs a Psychiatric Nurse Practitioner to provide individual substance use consultation and treatment and offers behavioral health services through the Metropolitan Center for Mental Health’s Family and Individuals in Recovery (FAIR) substance abuse clinic that employs a Certified Recovery Peer Advocate (CRPA). NYC Aging provides personalized aging service consultation and engagement. STRIVE holds weekly drop-in hours to provide technology support, education, and social engagement for clients as well as twice-monthly peer support groups. It also addresses emergency client needs and promotes independence through providing resources for home modifications, Metro Cards, and grocery store gift cards, among other essential items for older adults.
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