AGES (Assessing, Guiding and Empowering Seniors): Aging in Place Initiative

Organization Name: The Bridge

Project Title: AGES (Assessing, Guiding and Empowering Seniors): Aging in Place Initiative

Project Location: Citywide

Project Goals:
AGES addresses the critical needs of aging Bridge residents and aims to help them live in their homes for as long as possible. The Program offers a more cost effective and dignified model of care than nursing and adult home placement. It is focused on enhanced medical care and the integration of physical and behavioral health services. It endeavors to improve social, behavioral, and physical health outcomes for Bridge residents and increase community tenure by:
• Reducing seniors’ preventable hospitalizations/ER visits through facilitated access to community-based services
• Increasing seniors’ opportunities for socialization and community integration
• Improving health education through trainings targeting health literacy and self-management of chronic health conditions
• Reducing preventable transfers to higher levels of care through environmental modifications and connections to home care resources.

Project Description:
The needs of our seniors are more complex than those of the general aging population due to diagnoses of serious mental illness and chronic medical conditions that have been exacerbated by homelessness, institutionalization, and drug use. Our innovative program utilizes enhanced engagement, assessment, and monitoring protocols to link aging adults with appropriate community-based services and manage their age-related health challenges. The Service Team consists of a Licensed Clinical Social Worker, an RN, case manager, peer specialist, and social work interns. The team uses an agency-developed tool, and depression and substance use screenings, to evaluate residents over age 50 to determine their community support and health care needs. Since 2014, this initiative has assisted 156 seniors to remain in their homes, prevented 17 transitions to higher levels of care, and led to groups and workshops inspired by client-identified needs.

Community Impact:
AGES supports our clients’ connection to all aspects of community life and addresses critical gaps in the mental health system by offering personalized care to seniors with serious mental illness and chronic health conditions. The Program provides specialized services and referrals for aging clients whose needs fall “in between” nursing home care, assisted living facilities, and supportive housing and employs trauma-informed and culturally sensitive care to assist vulnerable seniors to navigate their environments. By providing transportation and opportunities to engage in community activities, Bridge seniors can socialize with their peers, reducing the detrimental effects of isolation. AGES also brings community awareness to mental health and aging issues, particularly as they relate to health care and accessibility, helping to combat stigma.

Organization Description:
The Bridge’s mission is to change lives, by offering help, hope and opportunity to the most vulnerable in our community. We are a highly- experienced nonprofit mental health and housing provider now in its 62nd year of operation. The Bridge has 46 programs in Manhattan, the Bronx, Brooklyn, and Queens that offer supportive housing to 828 individuals (50% of whom are 50 and older), mental health and substance abuse treatment, and community support services. In all, we work with over 2,400 New Yorkers. For 36 years, The Bridge has served as a leading housing agency in New York City and has been nationally recognized for its housing innovations. The Bridge’s portfolio offers a continuum of care for men and women including transitional, extended stay, and permanent supportive housing, providing individuals with choices and the ability to live in the least restrictive environment necessary for their rehabilitation and recovery.