A pilot program launched by Legacy Health Endowment in Stanislaus and Merced counties is aiming to help more middle-income seniors stay in their homes as they age by offering a network of patient services.
The Person-Centered Care program helps seniors stay in their home while accessing long-term healthcare options through a partnership between CareLinx by Sharecare, which provides a digital on-demand platform and network of tech-enabled home care providers; Community Care Choices, a nonprofit Palliative Care Program of Community Hospice, Inc.; TIN Rx, a pharmacy in Turlock; and Community Health Centers of America, a federally qualified health center.
"For too long, aging middle-income families have stood by the side of the road waiting for Congress to offer some assistance with long-term care costs. Instead of slamming the door in their face, we have brought together partners dedicated to creating solutions," said Jeffrey Lewis, President and CEO of Legacy Health Endowment. “Independence is a top priority for seniors, staying in their own homes is not only the most comfortable situation, but also typically the most cost effective one as well. The PCC program was created to assist the patient and their family or caregiver in achieving their maximum level of independence while improving overall health outcomes.”
The PPC program is free to the participant or their families. All services are funded through a grant from Legacy Health Endowment.
QUALIFIED ZIP CODES TO PARTICIPATE IN THE PERSON-CENTERED CARE PROGRAM
95301
Atwater, Buhach
95303
Ballico
95307
Ceres
95313
Crows Landing
95315
Delhi
95316
Denair, Montpelier
95322
Gustine, Santa Nella
95324
Hilmar, Irwin
95326
Hughson
95328
Keyes
95334
Livingston, Arena
95358
Modesto, Bret Harte
95360
Newman, Hills Ferry
95363
Patterson, Diablo Grande, Grayson, Westley
95374
Stevinson
95380-95382
Turlock, Cortez
95388
Winton, Cressey
The level of care offered under the pilot program includes respite care to skilled nursing services, and everything in between including behavioral healthcare. There is a minimum of 16 hours of in-home care per month. The services offered include: Access to durable medical equipment; physician-provided telehealth; in-home nurse and social worker visits; mental health services for patients and caregivers; advanced care planning services; home modifications for fall prevention; and support for prescription medications.
The Person-Centered Care program was created to assist the patient and their family or caregiver to achieve their maximum level of independence while improving overall patient care and health outcomes. It also strives to improve communication and understanding between providers, patients and caregivers by offering moderate care coordination like with medication assistance and fall prevention consultations.
The program will also ensure everyone involved in the patient’s care is fully informed about the care plan, the challenges and potential obstacles; ensure that socially isolated seniors, families and disabled residents have access to needed services to avoid unnecessary placement into a long-term care facility or hospital; allow caregivers to seek mental/medical care for their own needs to avoid burnout; provide services ranging from respite care to skilled nursing care in the patient’s home; protect the patient against food insecurity; aide the patient or family if they cannot afford to fill or refill a prescription medication; protect the caregiver spouse from burnout and financial collapse; and provide mental health services where needed.
The pilot program will begin enrolling qualified people living in 19 ZIP codes in southern Stanislaus County and northern Merced County. To be eligible, participants must be 55 years or older or be enrolled in Medicare with a qualifying disability; have a diagnosed chronic condition or a progressive disease; and demonstrate the need for community-based care in order to avoid placement into a long-term care facility.
If the spouse is the primary caregiver, the Person-Centered Care program works with them to determine what services or assistance they may need. For example, does she/he/they need time off from caregiving responsibilities? If so, the spouse would be assigned a respite care worker who would come to the home for a certain number of hours per week to give the caregiver a break.
Or, if the caregiver spouse is spending a significant amount of their savings on care, they may be eligible for a spousal stipend of $200 a month. These funds are to be used to aid the caregiver with the cost of food, medications, etc. To be eligible, the individual or couple could not have a household income greater than 400% of the federal poverty level and not be enrolled in Medi-Cal.
Participants start the enrollment process by calling 1-855-387-4360 or go online at to www.carelinx.com/pcc-2022 and complete a consultation request. A care advisor will follow up within 24 hours. The CareLinx by Sharecare team will determine what specific services are needed, enroll patients in the program and then create a care plan for each client based on their needs or what their caregiver may need. One of the strengths of the PCC program is its focus on the patient as well as the family caregiver, recognizing that if the caregiver is not healthy, the patient’s health may suffer.