Imagine this situation: You’re a caregiver for your mother who recently fell and will be discharged from the hospital tomorrow. Do you take her home with you and try to manage all of her medications and health needs while continuing to work? Or, is there a short-term facility that can better meet her needs? Which option should you choose? Which option will she accept? And who pays?
Just Call Us
“That’s when you pick up the phone and just call us,” says Connie Benton Wolfe, president & CEO of Aging & In-Home Services of Northeast Indiana in Fort Wayne. “We often say, ‘You don’t know us until you need us.’ And often, you may not even know what you need because you’ve never been in this situation before.”
Benton Wolfe says Aging & In-Home Services of Northeast Indiana (AIHS) is the federal and state designated Area Agency on Aging (AAA) for the nine county region of northeast Indiana – Adams, Allen, DeKalb, Huntington, LaGrange, Noble, Steuben, Wells and Whitley. AIHS has served this area since 1974 and is part of the national network of AAAs established under the Older Americans Act.
“We’re your premier resource for older adults, people with disabilities and their caregivers,” says Benton Wolfe. “Our Aging & Disability Resource Center (ADRC) staff answer more than 1,500 calls per month. They assist callers with information and resources including benefits assessment and enrollment. Consistently, the two most requested services are for Meals on Wheels and Geriatric & Disability Case Management.”
Benton Wolfe points out that often, people are calling AIHS in a moment of crisis – when they or their loved one is suddenly in a dire situation and the caregiver, if present, is not adequately prepared.
“We encourage people to start talking about ‘what if’ situations now, instead of waiting until the crisis actually happens,” she says. “It’s not always the easiest conversation to begin, but it’s easier to prepare for these decisions when you’re calm versus trying to make them when you, and everyone else, is in a very emotional state.”
To assist in beginning those difficult conversations, AIHS has become a leader in Advance Care Planning (ACP), the process of making your wishes known when you can no longer speak for yourself, and is the founding member of Honoring Choices Indiana, a statewide initiative committed to ensuring that an individual’s future healthcare preferences are honored.
Healthy. Happy. Home.
“Everybody wants to live at home for as long as they possibly can and our goal is to help people accomplish that,” says Benton Wolfe. “Gone are the days when staying at home meant you needed a family member to drop off a bag of groceries every now and then and check in on you. Today, caregivers are expected to handle more difficult tasks like medication management and wound care, despite having no training. On top of that, the people they’re caring for are living longer, thereby extending the length of time spent in those caregiving roles.”
Research has shown that addressing the Social Determinants of Health – such as, where you live, who you live with, your access to transportation and healthy food sources, as well as your access to healthcare – has a significant effect on your long-term health and well-being. AIHS has been a catalyst for providing support to address these determinants through several essential services across a continuum of care.
One of AIHS’ innovative programs, Care Transitions, began as a pilot project with Parkview Health in 2011 to reduce hospital readmissions by bridging the gap between hospital discharge and recovery at home. Based on the successful reduction in readmission rates, that program today operates under contract with several managed care organizations and a regional insurance company.
“We’ve continued to evolve our services to meet the changing needs of our clients across care settings. We are here to help you maintain your independence at home by providing the support you need – where you need it, when you need it.”
As the needs of the people served by AIHS have changed, so, too, has the agency itself.
“We’ve set and achieved strategic organizational priorities to improve client outcomes, enhance our service offerings with evidence-based programming and implemented standardized quality measures such as NCQA accreditation. We’ve diversified our revenue streams, and brought national recognition to the work we’re doing in northeast Indiana with community-anchored integrated health care,” says Benton Wolfe.
The Next Step in Integrated Care
As we age-in-place, the list of support and services necessary to do so grows longer and is both generic to the process and specific to each individual. To ensure better health outcomes, greater emphasis is placed on coordinating care across settings – in-home, primary care office, hospital, skilled nursing, etc.
Last spring, AIHS moved to a new headquarters off West Jefferson Boulevard, near the US 24/I-69 interchange on Fort Wayne’s southwest side to allow for expansion in AIHS’ integrated care program.
This year, AIHS will introduce a new program called PACE of Northeast Indiana at its former headquarters on Lake Avenue.
“PACE stands for Programs of All-Inclusive Care for the Elderly,” says Benton Wolfe. “This unique model of care combines clinical and social care under the same roof which has proven to allow participants to remain living in the community. The program evolved in San Francisco in the 1970s to meet the needs of low-income working families whose multi-generational family household included elders with long-term care service needs.” According to the National PACE Association, 90 percent of participants utilize Medicare and Medicaid to pay for cost of care across all settings.
“Older adults are often faced with a number of social issues, that impact their overall health and quality of life. They may be living on a fixed income and decline to buy medication due to the high cost. They may not have anyone at home to explain the medications they are taking, or to help with certain activities of daily living like cooking, bathing and dressing. They may not have transportation to their primary care physician’s office,” says Benton Wolfe. “PACE simplifies and organizes access to clinical and social services by having both under one roof and the participant’s care plan reviewed daily by an interdisciplinary care team comprised of medical and social services staff.”
While diversifying, AIHS has always maintained its commitment to its core mission of promoting dignity, independence and advocacy for all older adults, people with disabilities and their caregivers. “No two people are the same, and no two situations are ever the same. That’s why we say ‘just call us’ – that’s what we do. That’s why we’re here.”
Address: 8101 W. Jefferson Blvd. Fort Wayne, Indiana 46804
Phone: (260) 745-1200 (800) 552-3662