Residents in low-income supportive housing face many barriers when seeking and receiving adequate primary care and on-going, specialized chronic care services. They are among the most vulnerable, many with more than five (5) chronic conditions and challenging health trajectories.
Presbyterian SeniorCare Network (PSCN) will solve this problem by creating a collaborative triad among the service coordinator, primary care provider, and resident. The collaborative triad leverages the service coordinator’s knowledge of the resident, and resulting trusting relationship, to inform a more proactive, holistic approach to more fully address Hartford Foundation/Institute for Healthcare Improvement’s Age-Friendly Health Systems 4Ms (What Matters, Mentation, Medication, Mobility); a framework for helping healthcare system leaders and frontline teams deliver high-quality, age-friendly care.
Infusing our community-based social model with clinical expertise allows for early interventions in the chronic disease process, supporting residents to age in place, with better ability to self-manage conditions, and live their best lives.
Image courtesy of Presbyterian SeniorCare Network