Tammy is treating Ms. Gonzales, a 70-year-old woman, in her outpatient physical therapy clinic following a THR for a hip fracture resulting from a fall. Ms. Gonzales is now able to manage in her home without her walker and is plateauing in therapy. Tammy knows she will be discharging Ms. Gonzales soon, but she is concerned that if Ms. Gonzales stops doing her exercises, it will result in a decline in her function again and the risk of another fall. Tammy wishes there were some supports in the community that Ms. Gonzales could tap to help her sustain her new-found balance and safety awareness. Tammy must locate local "wrap-around services."
The U.S. Census Bureau reported that in 2010, there were more than 38 million Americans aged 65+, and projected that this number would rise rapidly1. Each and every year, one in three people over the age of 65 fall2. Physical therapists in all specialties and in all practice settings will be caring for aging adults who either have fallen or are at risk of falling.
Physical therapists report that they are often the primary care provider for aging adults who are either aging-in place or have sustained injuries from a fall and that they need to locate and/or coordinate wrap-around services. PTs may have limited contact with and, therefore, little knowledge of the wide array of services available to aging adult patients through the Aging Services Network3 and other medical and non-medical service providers. It is the goal of this article to help PTs locate and become more familiar with these extremely important "wrap-around services".
What are Wrap-Around Services?
In the aging services and mental health arena, the term "wrap-around" services4 usually means coordinated community-based services from many different service providers to support one client and their family as they deal with a complex physical, medical, or psychological issue. In the community-service provider arena, the term is used to describe the non-medical but very critical support services to allow a client to live at home safely and successfully despite physical and/or mental limitations. Wrap-around services include programs such as Meals-On-Wheels5, meals in congregate locations such as senior centers6 or churches, transportation to/from doctors' visits or grocery shopping, assistance with or doing errands, filling medication dispensers, providing respite to caregivers, completing house cleaning and/or repairs, or making periodic phone calls to check on a person living alone. This article will outline how to access and identify the resources available in your area.
Oftentimes, a patient may be discharged from physical therapy services prior to being able to perform tasks of cooking, cleaning, or other instrumental activities of daily living. Wrap-around services were created to support an individual's transition back to independent living.
Aging Services from Federal and State Government
As the service industry expands, there is a huge array of places to seek out services for aging adult patients. A few of these services may be funded through Medicare7 Part A through home health services, and in a number of states, some might be funded by Medicaid8 through the Medicaid Waiver system. The wide array of providers increases the possibilities, but also makes a single point of entry to locate these services more difficult. A discussion of those services is the first step.
The Aging Network was created when Congress passed The Older Americans Act9 (OAA) in 1965 to respond to the need for social supports and services for aging adults. The OAA established an agency called the Administration on Aging10 (AoA), part of the U.S. Department of Health and Human Services, to administer these social service programs.
Each state and territory in the United States has a State Unit on Aging11 You can locate yours at the State Agency Contact List found on this website: http://www.nasuad.org/about_nasuad/state_agency_website_links.html These state government offices work together with local aging offices that are commonly referred to as Area Agencies on Aging (AAAs)12.
AoA has also been leading efforts in the Aging Services Network to develop a "single point of entry" for assisting those who need information on community-based supports and services called Aging and Disability Resource Centers (ADRCs)13. Sometimes there are housed within Area Agencies on Aging, and sometimes they are completely virtual or telephone-based. ADRCs give information on which community-based services are available, from meal sites and caregiver supports to health and wellness programs in the community, and also lead a consumer through the process of identifying which services are needed and where their needs lie. A PT can locate an ADRC or AAA in your area by using the National Eldercare Locator Service (a good website to place on your favorites in the clinic.)
: Find local contact information for service providers through the National Association of Area Agencies on Aging (n4a) at http://www.n4a.org/about-n4a/?fa=aaa-title-VI
: Contact the Eldercare Locator at 800.677.1116 or to find home and community-based services at http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx
Organizations funded through your own state are usually easiest to find by doing an internet search including the words "aging services" and the 'name of your state'. Follow links to programs and services which will include a description of their services and their contact information. Many of these services will be provided at no or reduced costs to the client. In addition, you might also look around for small grant opportunities which are commonly available on an annual basis in a number of states.
: Search Engine: "aging services" + your state's name
Aging Services from Non-Profit Organizations
Not-for-profit organizations abound but can hide in plain sight. These include private, faith-based, secular, and special-interest groups that fund specific services that include a variety of aging services.
Faith-based service organizations14 are playing a larger role in assisting aging adults to age-in-place successfully since receiving federal funding. Search engines for aging services can be found at many websites including the following:
Secular, national aging service organizations and advocacy groups which provide services and/or search engines for service providers include:
Professional organizations supporting professional development in aging with an interest in falls prevention include:
The entrepreneurial spirit abounds in the arena of aging service providers. This is very apparent in the exhibit hall of the annual national Aging in America15 conference sponsored by the American Society on Aging16 (ASA) and previously co-sponsored by NCOA. Look in your yellow pages (hardcopy and online) for groups providing home-cooked meals, transportation, companionship, case management, technology support, fall alarm systems, and a wealth of other servicesCaregiver education on-line and at no cost
Your time in coordinating services is valuable and is reimbursable in the right context. If your referrals and contacts to wrap-around service providers are made to the organization while you are with your patient and working on patient and family education, this time can be included with your reimbursable services.
Need for Interdisclipinary Cooperation
One would be remiss to discuss fall prevention and wrap-around services and fail to mention the need for interdisciplinary collaboration. In discussing interdisciplinary medicine, Conklin (2007) concluded that, "Collaboration can yield synergy and innovation, but requires commitment from participants."17 In 2011, Ellis et al found that using an interdisciplinary evaluation and treatment planning team for aging adults resulted in far better outcomes. They concluded that "Comprehensive geriatric assessment increases a patient's likelihood of being alive and in their own home at up to 12 months."18 Many therapists live with a push for high productivity rates. Time to make phone calls, hold collaborative meetings, and locate external "team members" can be difficult. It is critical to the profession of PT as well as to those served, that all therapists maintain focus upon the ideals of excellent, evidence-based, effective practice; which includes collaboration with a broad range of -team members.
1. US Census Bureau: http://www.census.gov/population/www/projections/summarytables.html.
2. Shumway-Cook A, Ciol MA, Hoffman J et al. Falls in the Medicare population: incidence, associated factors, and impact on health care. Phys Ther. 2009; 89(4):324-332.
3. Administration on Aging (AoA): Aging Network: http://www.aoa.gov/AoARoot/AoA_Programs/OAA/Aging_Network/Index.aspx.
4. Zander K. Case management accountability for safe, smooth, and sustained transitions: a plea for building "wrap-around" case management services now. Prof Case Manag. 2010; 15(4):188-199.
5. Meals On Wheels Association of America: http://www.mowaa.org/.
6. NCOA National Institute of Senior Centers (NISC): http://www.ncoa.org/national-institute-of-senior-centers/.
7. Who Can Get Medicare-covered Home Health Care?: https://questions.medicare.gov/app/answers/detail/a_id/1347.
8. Medicaid Waiver & Demonstrations List: https://www.cms.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp.
9. Older Americans Act Amendments of 2006: http://www.doleta.gov/Seniors/other_docs/PublicLaw109-365.pdf.
10. Administration on Aging: About AoA: http://www.aoa.gov/AoARoot/About/index.aspx.
11. Eldercare Locator: States Units on Aging: http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx
12. National Association of Area Agencies on Aging: http://www.n4a.org/.
13. ADRC state locator: http://www.adrc-tae.org/tiki-index.php?page=HomePage.
14. Faith-Based Service Organization Locator: http://www.wilder.org/download.0.html?report=1975.
15. ASA Aging in America Conference: http://asaging.org/aia12
16. American Society on Aging (ASA): http://asaging.org/.
17. Conklin J SPLDSMCL. Enhancing service delivery capacity through kowledge exchange: the Seniors Health Research Transfer Network. Healthcare Management Forum. 2007; 20(4):20-26.
18 Ellis G WMONDLPRD. Cochrane Database Systematic Review: comprehensive geriatric assessment for aging adults admitted to hospital. Cochrane Database Systematic Review. 2011; 7(CD006211).
Lynn Beattie is vice president, injury prevention at the National Council on Aging. She can be reached at firstname.lastname@example.org. Mindy Oxman Renfro, PT, PhD, GCS,CPH, is an assistant professor at Touro University and can be reached at email@example.com. Priti Shah is aging service programs specialist at the U.S. Administration on Aging. She can be reached at firstname.lastname@example.org