AGES (Assessing, Guiding, and Empowering Seniors): Supporting Seniors Aging in Place in Supportive Housing

The Bridge’s Aging Services program addresses critical gaps in the mental health system by offering individualized care to seniors with behavioral health and physical health conditions living in supportive housing. In 2014, with approximately 800 beds in service, The Bridge recognized that we were not adequately equipped to support older residents who were experiencing geriatric conditions such as cognitive deficits, memory loss, and difficulty completing self-care tasks. These conditions, exacerbated by chronic health conditions, trauma, stress, and the long-term effects of psychotropic medications, were putting clients at an increased risk for unnecessary institutionalization in higher levels of care.

In response to this challenge The Bridge developed AGES, a practice-based approach that uses enhanced engagement, assessment, and monitoring protocols to link older adults living in supportive housing with appropriate community-based services to manage their age-related health challenges and maintain community tenure. Our approach offers a client-centered and cost-effective model that helps people stay in familiar surroundings and participate more actively in their own care.

Delivering specialized care to seniors living in community housing is a challenge that is not unique to The Bridge. The supportive housing system is not equipped to support and advocate for older adults to continue to live in the community as their needs change. Through the AGES intervention, The Bridge’s Aging Services program offers an innovative solution. We have developed a low-cost, team-based approach to harness knowledge and resources, internal and external to the agency, that enable older adults to remain in the community with their safety, dignity, and independence intact.

Program participation requires that individuals reside in Bridge housing, be age 55 or older, and require a geriatric intervention within the realms of physical health, mental health, and/or reducing hospitalizations. Clients are referred from a range of sources – residential staff, outpatient programs, The Bridge’s incident review committee recommendation, or clients who self-refer after an educational event.

Annually, AGES conducts an agency-wide Older Adult Needs Assessment (OANA) to identify high-risk clients who require support in a range of functional areas. Besides gathering critical demographic and clinical information on all residential clients age 50 and older, this is another avenue for identifying persons in need of service.

Once referred, AGES staff assess a client’s behavioral and physical health functioning, using the PHQ-9, AUDIT, DAST-10, and MOCA, among others, to create a comprehensive picture of the client’s needs. Together with the client, staff uses the results of these assessments, and the client’s self-identified goals, needs and barriers, to determine a plan of action. This plan may include referral to homecare and/or meal services, referral to a PCP, enrollment in a pooled trust, or escort to appointments. The RN provides education, coaching, and concrete services, e.g., insulin management and wound care. The team can provide in-home counseling, referrals to mental health services, and connection to appropriate treatment. All these services are closely integrated and coordinated with the client’s residential case manager and Health Home Care Coordinator, if the client has one.

One of Aging Services’ central aims is to reduce preventable hospitalization/ER visits through facilitated access to community-based outpatient physical and mental health services, elder care programs, and agencies that provide services that improve quality of life (SDOH). If a client is hospitalized, staff work to ensure a safe discharge by attending case conferences and advocating for comprehensive discharge plans. Staff consult with providers to ensure clients stabilize after crisis and coordinate with inpatient and rehabilitation settings for clients returning to residential housing, using a holistic, person-centered approach.

The Aging Services team blends into the rest of the supportive housing team and the broader array of Bridge programming, complementing the agency’s work while ensuring geriatric specialists are part of the conversation to offer guidance and resources. AGES is a time-limited intervention that supplements the services provided by supportive housing case managers. Joint meetings are held that include residential staff, Aging Services, and other providers to ensure coordination of care. In addition to delivering services to clients, the program’s goal is to develop the capacity of residential staff to plan and deliver services to older adults who might not need the intensity of AGES, but would still benefit from specialized services.

The Bridge’s Aging Services program is generously funded by The Fan Fox & Leslie R. Samuels Foundation, van Ameringen Foundation, The Dammann Fund, and Enterprise Community Partners, and supplemented by an annually renewed NYC Council initiative. Staffing includes a licensed clinical social worker, a full-time case manager, two part-time peer specialists, three MSW students, and an RN. Additionally, a consultant is creating an agency-wide staff training regarding advanced directives. This training will support staff in having conversations with clients about health care proxies and end of life issues, which directly impact client outcomes. Many clients living in supportive housing do not have relationships with their families. This training will ensure clients’ wishes are known and staff can best advocate on their behalf and avoid ethical dilemmas during medical treatment.

AGES is a replicable model for tenants whose needs fall between nursing home care and supportive housing case management. Our approach employs trauma-informed principles and culturally-sensitive care to help vulnerable older adults navigate their environments and stay in community housing for as long as possible. The AGES model not only supports clients’ connections to all aspects of community life, but is also a fiscally responsible option for meeting the complex health and housing needs of seniors with mental health conditions. Moving toward sustainability, The Bridge is exploring HCBS billing as an option for eligible clients, and we will be approaching at least one managed care company to develop a pilot program. In advance of approaching the MCO’s The Bridge has engaged Health Management Associates to assist us in creating systems and processes to collect and analyze data that will demonstrate positive outcomes, high consumer satisfaction, and cost effectiveness. We expect the data will support our anecdotal experience that AGES can be a billable, sustainable program that could be expanded beyond The Bridge to benefit seniors across supportive housing programs; allowing older adults to successfully age in place with an improved quality of life.

The Bridge’s mission is to change lives, by offering help, hope and opportunity to the most vulnerable in our community; Rebecca Heller can be reached at

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