A N N U A L R E P O R T 2 0 1 4

Somerville-Cambridge elder ServiCeS Celebrating Health & Independence

Everything that

we do as an agency

revolves around

keeping our clients

healthy and

independent.

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Over the past year, Somerville-Cambridge

Elder Services (SCES) continued its efforts

to adapt to the emerging challenges our

community faces. At the same time, we

worked hard to improve and grow our existing

programs which address critical needs of older

adults and people living with disabilities in

Somerville, Cambridge, and beyond.

Our participation in Medicare’s Community-

based Care Transitions Program (CCTP) has

been an important strategy to help us address

the emerging need for greater collaboration

between health care entities and community-

based agencies. SCES has been working

on this effort with Mystic Valley Elder

Services, the Cambridge Health Alliance, and

Hallmark Health since the end of 2012. Our

goal has been to reduce unnecessary hospital

readmissions among Medicare beneficiaries.

Thanks to this unique partnership, we were

able to reduce hospital readmissions among

the 4,700 program participants by 37%.

This is one of the strongest performances in

the country. Our success has resulted in an

extension of the program through 2015.

Another important theme at SCES in

2014 has been growth. In recent years,

the recognition by policy makers of the

importance of community-based care in

controlling long-term care costs has provided

opportunities for SCES to

expand. The agency now has

over 150 employees, more

than 300 volunteers, and a $30

million budget. In 2014 SCES

served a total of 3,400 clients in

its various programs, with strong

client growth in both Adult

Family Care and Senior Care

Options. Our Choices Program,

which serves MassHealth—nursing home

eligible individuals age 60 and over, provided

75 individuals with over 42 hours of care per

week in 2014.

This growth has brought opportunities and

challenges. It has allowed us to commit

additional resources to our mission and

support programs like wellness and volunteers,

and to enter into new collaborations with

healthcare partners. However, we remain

2014 In Review

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mindful of preserving our community-

based mission in the face of growth and

change. SCES wants to maintain its role

as an advocate for older people and people

living with disabilities. We want to be a

resource to help people maintain

independence and improve

quality of life. As we move

forward, we truly want the

voices of our clients to be heard.

We don’t want “person-centered”

to be just a marketing slogan;

we want it to actually mean

something in our daily work.

In that spirit, this year’s annual report is

devoted to another emerging challenge faced

by our community -- the growing incidence of

untreated mental illness among older adults.

In the following pages we explore our clients’

experiences with the issue, and our efforts to

address their needs.

John O’NeillExecutive Director

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In 2014 Somerville-Cambridge Elder Services

deepened its community collaborations in

the area of mental health. It also bolstered

its Connect Program, which provides clinical

case management to people with mental

health conditions who have had difficulty

remaining stable in their home environments.

The program focuses on providing the

services and support needed to ensure that

our clients with mental health challenges

are able to live with dignity, in the setting

of their choice. Our Masters-level, licensed

Social Workers assess, intervene and create

long-term care plans.

Our program includes a hoarding issues

initiative, funded in part by the Somerville

Community Collaborations for Mental Health

Affordable Housing Trust. One of the biggest

concerns addressed by this effort is clients

who are at risk of injury or losing their

housing because of hoarding. According to

the National Alliance to End Homelessness,

approximately half of homeless people suffer

from mental health conditions. There are

many programs focused on housing search,

but very few provide help with maintaining

housing. This service is essential–not

only because stable housing is integral to

maintaining mental health recovery–but

also because the process of eviction, housing

search and advocacy is a tremendous drain

on financial and human resources, and causes

unnecessary anxiety for a person who is

already suffering from mental health issues.

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In addition to expanding our own clinical

programs in the past year, SCES has been

working with members of the local aging

and mental health network to achieve a

holistic approach to wellness and recovery

through the Cambridge-Somerville Aging and

Mental Health Coalition. The Coalition is

part of the Massachusetts Aging and Mental

Health Coalition, a statewide membership

organization dedicated to improving

awareness of the critical problems facing

elders with mental health and substance use

conditions. The coalition provides education

and advocacy on issues related to mental

health, recovery, and wellness.

This year, the president of the SCES

Board of Directors, Elizabeth Aguilo, and

SCES Community Social Worker, Cassie

Cramer, volunteered as co-chairs of the

Cambridge-Somerville Aging and Mental

Health Coalition. The group consists of

representatives from the Cambridge

Council on Aging, Cambridge Health

Alliance/Geriatric Services, Paine Senior

Services, Samaritans, Somerville-Cambridge

Elder Services, and the Somerville Council

on Aging.

The Coalition has been active in legislative

advocacy, sponsoring cross-trainings for

workers in aging and mental health, and in

community education. Those efforts include

film/discussion groups, workshops on suicide

prevention, screening and outreach for

depression and substance use at Councils on

Aging, Cambridge Adult Education, and elder

health and wellness fairs.

Holistic Approach to Wellness & Recovery

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Stories of Support and Recovery SCES Partners with Legal Services

SCES has a long history of collaborating with Cambridge and Somerville Legal Services. The two groups have worked on many issues over the years including housing, Medicare/Medicaid advocacy, and nursing home resident rights. More recently the two organizations have worked together to address the needs of the growing number of older adults who have mental health issues. Legal Services Attorneys Deborah Filler and Ellen Shachter regularly partner with SCES staff including social workers from Protective Services, Connect, AgeInfo, and Home Care to ensure that clients with mental health challenges have the support and advocacy they need to access services, stay housed, and receive treatment.

Attorneys Filler and Schachter were involved in a recent case with SCES where they were able to prevent the eviction of a severely disabled elderly woman and her disabled son. The elder and her son lacked the physical and emotional resources to properly maintain the condition of the apartment. Mental health challenges exacerbated the situation. The social worker from Connect was able to bring in heavy chore cleaners, arrange for ongoing housekeeping services and provide

storage containers for the tenants’ clothes and belongings. Most importantly, the Connect social worker was able to gain enough trust with the largely homebound elder to put appropriate services in place. Until that point she would not allow legal services to take necessary actions to prevent the family’s eviction.

In another case, the SCES Connect social worker was sent to assist a severely disabled elder who had recently been released from a psychiatric hospitalization, and who was facing eviction. Before SCES Connect’s involvement, the housing manager sought the intervention of legal services whenever the tenant’s behaviors were spiraling out of control due to mental illness. While legal services could handle the legal aspects of the case, it could not provide the intensive clinical and case management services this client so badly needed.

Fortunately, the Connect social worker was able to work with this elder in her home environment which was critical because of her agoraphobia, that had prevented her from accessing and maintaining more traditional

mental health resources outside the hospital. After contacting the client and building rapport, the Connect social worker arranged to have a new lock box installed; a key could be stored outside the tenant’s apartment so the client would be able to access the apartment if locked out.

The social worker also arranged for cleaning services and provided an emotional outlet for this client who needed to connect with others when feeling anxious or overwhelmed. The social worker continues to maintain contact with her client’s psychiatrist as well as legal services in order to provide a coordinated approach to maintaining the elder’s tenancy.

Somerville-Cambridge

Elder Services is dedicated

to providing the

resources necessary to

maintain the dignity and

independence of

our clients with mental

health challenges.

Misael’s Story

One of the greatest challenges to helping clients with mental health issues is their own awareness of the condition. Culturally, there is often a serious stigma associated with admitting to a mental health disorder and a legitimate fear that it might lead to loss of housing or even personal freedom. In these cases, often SCES social workers are the last line of defense in keeping clients at home, healthy, and living with dignity.

One such SCES client is Misael, who was born in Puerto Rico. Throughout his life he travelled between Puerto Rico and the continental United States doing construction work. Misael enjoys music; he plays the trumpet and has a guitar in his apartment. Three years ago he moved to Cambridge, close to his daughter, Wanda. About a year and a half ago, an undiagnosed and untreated mental illness led to behavior that threatened his housing. While he was hospitalized, his property manager filed for eviction. Misael was told he could not return home. He recalls this time with great emotion and says that he felt “very bad, depressed” and “worried that he would be on the street.”

Through the SCES Connect program, Misael obtained legal support from Community Legal Services and Counseling Center. He received help enrolling in a Senior Care Options managed care plan, where he would get ongoing treatment. He says the Connect program brought him “comfort and support” and he felt that his social worker was “willing to go out of their way to help.” Misael returned to his apartment, where he continues to live with support from the SCO program and regular visits from his daughter.

These stories and many others like them are daily reminders that whether it is through one of our community information sessions, support groups, or direct intervention by our clinical and collaborative legal staff, Somerville-Cambridge Elder Services is dedicated to providing the resources necessary to maintain the dignity and independence of our clients with mental health challenges. We look forward to continuing our community collaborations in 2015 and beyond.

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Somerville-Cambridge Elder Services Programs and Services

Information and Resource Center assists anyone - young or old - seeking information and resources on a wide variety of aging or care giving issues.

Elder Care Advice is a free service that provides information, advice and education to older people, families, and caregivers. Elder Care Advisors offer in-home, in-office or phone consultations to residents of Cambridge and Somerville or to individuals caring for an older person who lives in either of the two communities.

Adult Family Care provides supportive services in a host’s home for older adults and people with disabilities who find living alone difficult.

Care Consultation Service guides families and caregivers through the sometimes confusing terrain of available eldercare options.

Case Management provides free in-home assessment, care planning, information about resources, and on-going monitoring of services.

Community-based Care Transitions Program (CCTP) assists patients in making a successful transition to home after a hospitalization thereby reducing unnecessary hospital readmissions.

The Family Caregiver Support Program offers caregivers information about services, provides educational programs and short-term individual or family consultation.

Group Adult Foster Care provides daily, in-home personal care assistance to older adults and people with disabilities.

Home Care Program provides state-subsidized services to eligible older residents of Cambridge and Somerville who need assistance so they may continue to live safely at home.

Long-Term Care Ombudsman Program provides advocacy for residents of nursing and rest homes in order to improve their quality of life and care.

Often, people don’t know where to

turn for help with aging, disability

or care giving issues. Since 1972,

Somerville-Cambridge Elder Services

(SCES) has been the area’s aging

information expert. SCES helps older

people remain safe and independent

in their own homes by providing a

wide range of supportive services. In

addition, SCES offers information and

advice to caregivers, family members,

and community members.

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Somerville-Cambridge Elder Services Programs and Services

Medical Escort Program matches frail seniors with a volunteer who accompanies them to medical appointments.

Medical Advocate Program matches volunteers with a senior who needs help understanding his or her medical care. Medical Advocates become familiar with the senior’s medical issues, and accompany them to doctor’s visits to make sure their concerns are addressed, and to make sure the senior understands the doctor’s diagnoses, prescriptions and instructions.

Memory Disorder Service provides in-home consultation to families, caregivers, and older adults dealing with the effects of memory problems.

Money Management Program matches trained and insured volunteers with older adults who need help paying bills, writing checks, balancing their checkbooks, budgeting monthly income, and running bank errands.

Nutrition Services: Meals-on-Wheels delivers meals to older participants’ homes.

Congregate Meal Sites serve hot lunches in senior centers and elder housing buildings.

Protective Services for Elders At-Risk investigates reports of elder abuse, neglect and financial exploitation, provides case work, and coordinates services necessary to eliminate or remedy the effects of abuse.

Respite Services for Caregivers offers caregivers relief from their caregiving tasks and time to care for themselves.

The SHINE Program (Serving Health Information Needs of Elders) is a network of volunteer health benefits counselors who have been trained and certified to provide information and assistance regarding health insurance and benefits to older people, disabled Medicare beneficiaries, and their family, partners, and caregivers.

The SeniorPet Program helps seniors with pet issues such as medical needs, food assistance, pet concerns, and proper procedures to insure pet safety as well as uniting seniors with older pets.

The Take Charge Program is based on the philosophy that older adults should have choices about the way they receive services and who provides them. With the help of SCES staff, elders can hire, train, schedule and supervise their own workers to assist with personal care and homemaking tasks. Elders can choose their workers -- they can be partners, friends, neighbors, or any family member (except a spouse).

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State-EOEA 54%

Medicaid & Medicare 36%

Federal Awards 3%

Programs Fees & Donations 4%

Investments 2%

Subtenant & Other .1%

Charitable Donations & In kind 1%

State Home Care 19%

Area Agency/Supportive Services 2%

Nutrition 8%

Senior Care Options Program 6%

Adult Family Care 20%

Enhanced Community Options 6%

Protective Services 3%

Community Choices 28%

CC TP 6.0%

Other 3%

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2014 Agency Statistics

People Served:

State Home Care Program: 1,600

Senior Care Options: 1,500

Complex Care Program: 75

Adult Family Care: 277

Protective Services: 250

Meals-On-Wheels Program: 1,285

Brown Bag: 559

Community Meal Sites: 1,055

Family Caregiver Support Program: 341(includes Memory Disorder Service and Elder Care Advice)

Options Counseling: 278

Benefits Screening/Counseling (SHINE): 209

Little Necessities for Men: 41

Little Necessities for Women: 57

Little Necessities for Dementia: 5

Nutrition (Meals Served)

Meals-on-Wheels : 226,230

Congregate Meals: 83,930

Health/Wellness &Prevention

Chronic Disease Self-Management and

Chronic Disease Self-Management for

Diabetes: 42

Healthy Eating: 33

In-Home Fall Prevention: 26

Healthy Ideas: 25

Number of Volunteers

Caring Neighbors: 36

ElderFair: 17

Medical Advocate Program: 14

Medical Escorts: 22

Money Management Program: 69

New Friends Program: 48

Nursing Home Ombudsman Program: 6

Nutrition Meal Sites: 12

SeniorPet Program: 16

Brown Bag: 38

Holiday Bagging: 13

Spiritual Caregiving: 10

Thanksgiving Meals-On-Wheels: 43

Office Volunteers: 5

Revenues by Source

State-EOEA 54%

Medicaid & Medicare 36%

Federal Awards 3%

Programs Fees & Donations 4%

Investments 2%

Subtenant & Other .1%

Charitable Donations & In kind 1%

State Home Care 19%

Area Agency/Supportive Services 2%

Nutrition 8%

Senior Care Options Program 6%

Adult Family Care 20%

Enhanced Community Options 6%

Protective Services 3%

Community Choices 28%

CC TP 6.0%

Other 3%

Expenses by Program

Elizabeth Aguilo (President)Susann L. Wilkinson (Vice-President)Ligia Taylor (Treasurer)Edna Stamp (Clerk)Joseph CaparcoTheresa Connolly

Kathryn EratHazel F. EvansEllen FriedmanStephen H. GardinerLora GreenPhyllis KornfeldRoma Mayur

Art MazerJuanita MerandaSusan PachecoLaura RamsayLisa Montuori TrimbleNeal A. Winston

Management TeamJohn O’Neill, Executive Director

Mary Ann Dalton, Assistant Executive Director

Nancy Willbanks, Chief Financial Officer

Rachel Berry, Home Care Director

Stephanie Becker, Protective Services Director

Anne Fowler, Director of Clinical Services

Miranda Heibel, Director of Aging Information

Jeanne Leyden, Adult Family Care Director

Deb McLean, Community Meals Program Director

Suzanne Tilden, Director of Human Resources

Community RelationsDonald Donato, Director of Planning & Community Relations

Margarida Mendonca, Community Relations Support Specialist

2014 Board of Directors

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State-EOEA 54%

Medicaid & Medicare 36%

Federal Awards 3%

Programs Fees & Donations 4%

Investments 2%

Subtenant & Other .1%

Charitable Donations & In kind 1%

State Home Care 19%

Area Agency/Supportive Services 2%

Nutrition 8%

Senior Care Options Program 6%

Adult Family Care 20%

Enhanced Community Options 6%

Protective Services 3%

Community Choices 28%

CC TP 6.0%

Other 3%

State-EOEA 54%

Medicaid & Medicare 36%

Federal Awards 3%

Programs Fees & Donations 4%

Investments 2%

Subtenant & Other .1%

Charitable Donations & In kind 1%

State Home Care 19%

Area Agency/Supportive Services 2%

Nutrition 8%

Senior Care Options Program 6%

Adult Family Care 20%

Enhanced Community Options 6%

Protective Services 3%

Community Choices 28%

CC TP 6.0%

Other 3%

Somerville-Cambridge Elder Services is operated by a local volunteer Board of Directors, a majority of whom, by law, are older people.

61 Medford Street

Somerville, MA 02143-3429

Phone: 617-628-2601Fax: 617-628-1085

Email: info@eldercare.org

Web: www.eldercare.org

Elizabeth Aguilo President

John O’Neill Executive Director

This agency and its programs are funded in part by contracts with the Massachusetts Executive Office of Elder Affairs.

SCES Annual Report Donald Donato, EditorChris Dearborn, Graphic Designer www.spacestationz.com

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