Canvas Health’s Service Coordination program provides tools and support systems to seniors and adults with disabilities in 11 Washington County apartment complexes so they can maintain their independence, safely and with dignity, no matter their means.
Independent living for seniors and adults with disabilities can include many challenges, in addition to aging and ability, including interpersonal conflict, substance abuse, and social isolation.
Canvas Health’s two (soon to be three) services coordinators are not direct providers, but they work as a single point of contact for clients in the apartment complexes they serve. During a single day, service coordinators may:
Manage and help provide access for clients to supportive services in community.
Service coordinators are a liaison between residents and direct providers. They identify needs and use their connections and knowledge to ensure residents get what they need. A resident story, told by a service coordinator:
An elderly couple found themselves overwhelmed when one spouse suffered a severe stroke. The healthy spouse asked me if he could get any help for his wife—he was overwhelmed with the tasks of caregiving and housekeeping. Clearly, he needed respite care, help with household upkeep, and personal cares for his wife. He, as many other independent seniors, was reluctant to ask for help. I shared information about the Alternative Care and Elderly Waiver programs. He wanted to think about it. After a month or so he returned and asked if I would meet with him and his son—we scheduled an appointment. After the meeting and making a call to Washington County to begin the referral process, he told me his son could handle everything from there on out. Approximately six weeks later I saw him and asked how everything went. He told me “we were denied” and “I guess that is that.” I asked the reason for denial and he didn’t know and his son didn’t understand the paperwork/communication received from the County. I asked if I could call and see what I could find out and he agreed. After speaking with the County, the reason for denial was due to being under–income/asset limits! I received permission to make a new referral for the other program and to-date the application is approved and services will be starting shortly.
Provide case management services.
Service coordinators work to identify needs, connect residents to supportive programs, and follow through to ensure a resident’s needs are met, such as in this story from a service coordinator:
A resident of almost five years failed an apartment inspection for the first time. Property management suggested talking with the service coordinator to possibly get assistance. Although a tenant for almost five years, the resident had never availed herself of service coordination services. After meeting with the resident and gathering information, I was able to begin the processes to pass the re-inspection, receive SNAP/NAPS benefits, change health coverage from Medicare only to MA/MSHO program (no co-pays, increased services including medical visit transportation), apply for and receive energy assistance, apply for and receive a ‘free’ cell phone, provide a resource for dental services, introduced her to our local food shelf, and facilitated enrollment in the Elderly Waiver program which includes housekeeping services. Several months after services and supports were in place, the resident expressed her gratitude with a lovely thank-you card.
Develop programs and resources that support residents’ wellness.
Service coordinators do much of this through bringing in volunteers to provide workshops and other health events such as tax preparation, flu shot clinics, blood pressure screenings, and other presentations. One such benefit is in the following story from a service coordinator:
I had a speaker come out to all of my buildings from Midwest Hospice Services to talk about hospice care. A resident was struggling to care for her elderly husband that had Alzheimer’s disease and other health issues. She was burnt out and her personal health had started deteriorating due to the 24/7 care of her husband. She was able to get help from the agency with end of life care for her husband and she was able to have a break from caregiving with the five night facility stay they offer for patients. Everything was paid for through Medicare and the agency took care of a lot for her husband as his health declined. She was unaware of these types of services prior to attending the presentation set up through service coordination. Her husband passed away within a few months of being on hospice but her health had become better with the extra help and support from this agency.
Someone to talk to.
Service coordinators also serve as a listening ear and trusted voice. One such story from a service coordinator illustrates the resident-coordinator relationship:
I had a resident come to me for supportive counseling about her son finding her after she had put him up for adoption 60 years ago. She was overwhelmed and looking for guidance on how to prepare for him and his wife coming to visit her. I helped her decide on what refreshments to provide and talked over what she wanted to ask him as well as what questions her long lost son might have. She was grateful for our conversation and felt more at ease before their visit. I do a lot of supportive counseling at my main building. Many residents just need someone to listen and understand. I am honored to be trusted with their personal lives and I always do my best to try and help.
Canvas Health’s service coordinators are an important part of our continuum of care that stretches across all ages groups, needs, and ability levels. By helping these Washington County residents living independently, Canvas Health’s service coordinators are saving them money and ensuring their lives remain dignified.