Provider Spotlight: Jamaica and Flushing Hospital Work to Support Aging in Place

Dr. Susan Beane, Executive Medical Director, Healthfirst

Dr. Elizabeth Brondolo, Professor at St. John's University; Director of the Collaborative Health Integration Research Program (CHIRP)

New York City’s walkable, tight-knit neighborhoods make it easy for residents to build and maintain a sense of community. So it makes sense that aging in place is especially important to New Yorkers.

Indeed, most older Americans want to be able to age in place, with 88% of seniors saying it’s important for them to stay in their homes for as long as possible.

But nearly half also said they’d given little to no thought to what it would take to remain in their homes, and only one-third had installed things like door handles that are easier to open than knobs or raised toilet seats and handlebars that reduce the risk of a fall in the bathroom.

And even though aging in place is a widespread desire, it’s increasingly difficult to do so — especially in New York City. Seniors are more likely to use government assistance programs than the general population, so they must get by on tighter budgets in one of the world’s most expensive cities. Black and Hispanic residents face an additional obstacle: systemic segregation has left many neighborhoods disadvantaged and largely devoid of the home care services increasingly necessary to support aging in place.

It’s against this backdrop that the Jamaica and Flushing Hospital Medical Centers partnered with the New York City Department of Aging to provide healthcare and social services to New Yorkers that will help them live independently for as long as possible.

Here, Dr. Elizabeth Brondolo, director of the Collaborative Health Integration Research Program (CHIRP), shares the progress and potential of this program.

What makes aging in place possible?

The goal of this program is to assess the community-based, integrated services provided to people aged 55 and older to see if they give them a better chance at remaining at home. We recruit participants from multiple sites through community referrals, we conduct physical and mental health assessments covered by a grant from the Office of Mental Health, and we follow their utilization of healthcare and community-based services over a five-year period. We want to see if utilization patterns match the clinical and social needs identified in their assessments, and we want to see if utilization of preventive rehabilitative services has a positive effect on readmission rates and other clinical outcomes.

With any community-based health program, and especially with one funded by a grant, it’s critical to ensure limited resources are allocated properly. That way, a program can target the individuals with the most pressing needs and achieve the outcomes that most closely align with program goals.

In our case, this meant understanding what makes it possible for someone to age in place, as opposed to someone who requires institutional long-term care. This is harder than it may sound, as people over 55 and the communities they live in are quite heterogeneous. Multiple sociodemographic, clinical, and healthcare access factors affect whether someone can stay in their home.

With the help of Healthfirst, we analyzed a combination of clinical, claims, and publicly available data to determine risk factors and identify specific population subgroups who faced those risks. The public datasets provide us with an important snapshot of each neighborhood. Information including demographics, crime, pollution, and the levels of education and professional jobs in a community give us a sense of what resources are available and who may — or may not — be able to access them.

From there, we began to develop a framework for more personalized psychosocial treatment, with interventions tailored to individual psychological, medical, and social needs. We also developed these interventions through the lens of prevention: What will keep someone from needing to go to the emergency department? What can prevent an inpatient stay? How can we help avoid institutional long-term care?

Understanding needs at the community level

Community is at the heart of this work. For starters, we’ve assembled a multidisciplinary team that comes together once a week to assess our work. This group includes health system and health plan representatives, along with the New York City Department for the Aging.

More broadly, we are very intentional about looking at social determinants of health and at a community level, not just an individual level. This helps us understand how systemic racism and segregation have limited access to care — but also how interwoven social, cultural, and religious networks have emerged to provide support in the neighborhoods we serve. This way, we’re able to partner with community organizations that are having a significant impact already without replicating or replacing their work.

The goal of the program is to produce insights that will be able to tell a provider at the point of care that an individual patient is at a high risk of no longer being able to live independently. We’re working to reach that point by continuing to refine and expand the data that we gather. This is helping us determine what interventions are working best and identify risk factors at a more granular level — both of which will allow more New Yorkers to remain in their beloved homes and communities as they get older.

This is the third in a series of posts highlighting partners of Healthfirst who are working to address various forms of health inequity for the New Yorkers we serve together. Our first post looked at Northwell Health’s use of data to address disparities in care, and our second explored how New York City Health + Hospitals is working to reduce maternal mortality rates in Black women.