Baltimore Elderly in "Safe at Home" Program Experience Fewer Falls, Better Health
In 2001, a consortium of Baltimore agencies launched Safe at Home, a program that provided a coordinated set of services, including home modifications to reduce the risk of falls, to help low-income elderly residents of Southeast Baltimore remain healthy and continue living in their own homes. A research team from Johns Hopkins University conducted an evaluation of Safe at Home.
- Safe at Home served 435 clients and made 865 modifications and repairs at clients' homes.
- Safe at Home clients were substantially less likely to suffer a fall after enrolling in the program than they were in the previous year.
- Clients were more likely to report that they were in good health after joining the program.
RWJF supported the project with a grant of $458,025.
Some 30 percent of seniors suffer a fall each year, and 10 percent of those falls result in serious injuries, according to a 1997 study published in the New England Journal of Medicine. Serious falls often lead to disability and costly institutionalization. Simple home adaptations such as railings and adequate lighting can prevent falls, but many elderly households lack the resources to make these improvements.
Besides the risk of falls, reduced mobility affects the health of the elderly in other ways. It can be difficult to make medical appointments or pick up prescriptions. Immobility is also linked to depression, poor nutrition and reduced cardiovascular fitness.
In 1999, there were an estimated 76,000 senior households in Baltimore with incomes below $25,000, according to staff at the South East Community Organization, a coalition of community and service organizations in Baltimore. To the extent that help with home adaptations was available to them, it was rarely coordinated with efforts to address other health needs unless an elderly person faced an imminent risk of requiring a nursing home placement.
In 1998, RWJF provided a grant (ID# 032119) to the Baltimore Medical System (which serves low-income city residents through a system of community health centers) to design a community-based program that would provide medical and social services to elderly residents who were not yet frail, thus avoiding or delaying nursing home placements. Although the full program was not implemented, Baltimore Medical System started a fall prevention program as part of this effort.
In 1987, the RWJF Board of Trustees authorized $8 million to fund a two-year trial of a matching grants program to be called the Local Funding Partnerships program. Many matching grants programs set up by national foundations seek to replicate ideas formulated by the national institution itself.
Local Funding Partnerships was to be different. The local community would identify a pressing need, design the strategy for addressing it and put together a funding package that would provide at least one dollar of outside support for every one dollar of RWJF grant money. Each project would have one lead local funder, but additional supporters would be welcomed.
To be eligible, a project would have to fall within the general scope of RWJF's interest in health and health care. But a proposal would not have to meet the kind of specific criteria common to other RWJF programs. Instead of top-down, Local Funding Partnerships would be bottom-up with an emphasis on innovation. RWJF hoped this local "ownership" would ensure sufficient support to keep the project going long after the RWJF grant ended.
Safe at Home sought to provide a coordinated set of services that would help low-income elderly residents of Southeast Baltimore remain healthy and continue living in their own homes. Four local agencies collaborated on the project:
- South East Senior Housing Initiative, a project of the South East Community Organization, promoted support services for community-based seniors. The director of the Initiative, Peter M. Merles, M.S.W., served as project director. The housing initiative's advisory board served as advisors to the project.
- Baltimore Medical System operated six community health centers in East Baltimore, two of which were dedicated to geriatrics. Its director of senior services development at the time of this grant, Rebecca Ruggles, had served as project director on the 1998 RWJF grant to Baltimore Medical System.
- Baltimore City Commission on Aging and Retirement Education, the local Area Agency on Aging, ran an adult day care program and three senior centers in East Baltimore.
- Banner Neighborhoods operated a home maintenance and repair program for low-income seniors in East Baltimore.
The project targeted an estimated 2,000-plus households with a head of household over 65 years of age and an annual income below $25,000 living in Southeast Baltimore. The typical Safe at Home intervention consisted of several steps:
- An elderly resident, perhaps referred by a physician or community group, would approach the Baltimore City Commission on Aging and Retirement Education.
- An intake coordinator from the commission would collect initial eligibility information and conduct an assessment.
- South East Senior Housing Initiative staff would conduct a home safety and repair evaluation. For needed repairs, Safe at Home either paid for the repair or, if the homeowner was eligible, made a referral to other local agencies.
- South East Senior Housing Initiative staff, in consultation with the resident's physician, would develop a Home Service Plan. In addition to home repairs, the plan might include services to meet nutritional and social needs, help applying for public benefit programs such as Food Stamps, and transportation assistance.
- A service coordinator at either the South East Senior Housing Initiative or Baltimore Medical System would maintain ongoing contact with the resident, referring them to appropriate services and consulting with the physician on changes in the resident's health and needs.
The France-Merrick Foundation, the lead local funder, provided grants totaling $190,000. Seven other funders also provided project support. See the Appendix for a complete list.
The South East Community Organization contracted with the Center on Aging and Health at Johns Hopkins University to conduct an evaluation of the project. Linda P. Fried, M.D., M.P.H., the center's director, led a team of researchers conducting the evaluation. Funds from RWJF and the Jeanette Weinberg Foundation supported the evaluation.
Researchers interviewed Safe at Home participants when they enrolled in the program and again three months and six months later. Baseline interviews covered:
- Participant characteristics (age, sex, race, marital status).
- Health status and number of medical conditions.
- Functional status with regard to activities of daily living.
- Use of assistive devices such as canes and walkers.
- The number of falls and fall-related injuries they suffered over the previous year.
Follow-up interviews asked participants about any falls they suffered since joining the Safe at Home program, and about their health in that time, including hospitalizations and nursing home placements.
In an April 2006 report, Safe at Home Program Report (see the Bibliography), the evaluators reported the following results of the project:
- Between 2001 and 2004, Safe at Home served 435 clients. Most were age 75 and over, and three-quarters were women. Three-quarters of the clients reported that their health was fair or poor, and most had multiple chronic health problems. Some 63.5 percent said they had fallen at least once in the year before enrolling in the program, a rate 1.5 to 2 times higher than is typical for people over 65.
- Project partners made 865 modifications and repairs at clients' homes. Of these, 409 cost more than $50 each for example, widening a doorway or fixing outside steps. Smaller, less expensive changes included removing rugs and installing a hand-held shower. Participants also received 1,542 pieces of equipment, ranging from wheelchairs and portable commodes to button hooks and bag grippers.
- Safe at Home clients were substantially less likely to suffer a fall after enrolling in the program than they were in the previous year. Participants reported suffering an average of 0.46 falls per month in the year before joining the program, and only 0.13 falls per month once in the program. (These figures are adjusted for age, sex, physical disability, health and marital status.)
- Clients were more likely to report that they were in good health after joining the program. The proportion reporting excellent or good health rose from 23 percent at enrollment to 28 percent six months later. The proportion reporting that they were in poor health declined from 33 percent to 11 percent.
- The researchers could not document a reduction in hospitalizations or nursing home placements during the study period. The short follow-up time and small sample size prevented an assessment of the cost-effectiveness of the program, according to the evaluators.
- Clients were very satisfied with the program. Almost all said they were happy they participated, and more than 90 percent believed the program had improved their quality of life.
- Recruit local funders and stakeholders to sit on advisory boards and let them in on the details of the experience. Tell about the problems and tell about them sooner even if it worries people so that the right people can address the problems. By broadening the range of stakeholders and marketing your project to a diverse set of interest groups, you can win wider support. (Project Advisor)
- Make sure government is a stakeholder, not just private funders. Build a broad base of government support. "This is where sustainable funding can come from and the program can get some security," according to project advisor Ruggles. (Project Advisor, Local Funder)
- Focus on sustainability and pursue multiple transition funding sources right from the beginning. "Even a very valuable program with measurable positive impact and multiple sustainability strategies can die despite all best efforts," noted Ruggles. (Project Advisor, Local Funder)
- Make people in government care about who you are serving and what you are doing. "If the population you are trying to serve is not important to politicians, there may be little you can do to gain their support. Some bad outcomes cannot be avoided through hard work and being mission-driven. Safe at Home had a lot going for it, but one by one, its stakeholders withdrew and our markets evaporated," said Ruggles. (Project Advisor)
- Begin with the end in mind and constantly talk about where things will be several years in the future. Consider who will be buying what you are offering in the future so you are prepared for environmental changes that may occur. (Project Advisor)
AFTER THE GRANT
At the outset of Safe at Home, project staff identified several potential sources of sustainable funding that they expected would enable the program to continue after RWJF and local funding ended. Several changes in the local environment frustrated these hopes:
- Project staff planned to market Safe at Home to local Medicare HMOs as a source of benefits for low-income senior members, arguing that reducing falls could save money on health care costs. According to Ruggles, "At the time there were several HMOs existing, but within three to four years the Medicare HMOs were no longer in business. This was a critical strategic loss."
- At the time Safe at Home began, the state of Maryland had applied to the federal government for an expansion of its Home and Community-Based Services Waiver to allow higher-income seniors to qualify for home-based services, including supports normally available in assisted living facilities. Project staff hoped this would allow them to receive Medicaid reimbursement for services provided by Safe at Home. While Maryland got the waiver, it did not operate as well has Safe at Home staff had hoped. "It never worked in Baltimore," Ruggles said. "It was a huge disappointment."
- When Baltimore was experiencing population loss in the years before the grant period, seniors were less likely to leave the city than other age groups and, thus, became a higher proportion of the population. Over the course of the grant period, significant neighborhood revitalization brought an influx of younger residents, shifting the population mix and the resulting focus of social service agencies and city government. One result was that Baltimore lost a portion of government funds for programs addressing issues of aging, according to the Baltimore City Commission on Aging, because seniors had become a smaller percentage of the population.
Without prospects for sustainable funding, the advisory board decided to phase out the program in the fall of 2004.
As of September 2006, Ruggles and local funders of this project are applying lessons learned from the Safe at Home experience to a new Baltimore project funded by the Local Funding Partnerships program. Threshold to Recovery offers a range of nontraditional approaches to substance abuse recovery to people at all stages of addiction and recovery.
GRANT DETAILS & CONTACT INFORMATION
Home Intervention and Support for Low Income Seniors
South East Community Organization (Baltimore, MD)
Dates: August 2000 to July 2004
The local funders of Safe at Home are the following (located in Baltimore, Md., unless otherwise noted):
- France-Merrick Foundation (Lead local funder), $190,000
- Abell Foundation, $33,617
- Annie E. Casey Foundation, $20,000
- Erickson Foundation, $25,000
- Jonan Foundation, $15,000
- Marion I. & Henry J. Knott Foundation, $67,000
- Middendorf Foundation, $30,000
- Harry and Jeanette Weinberg Foundation
Owings Mills, Md., $75,000
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Gajadhar R, Barron J, Barr A and Fried LP. Safe at Home Program Report. Baltimore: Johns Hopkins Bloomberg School of Public Health and Johns Hopkins University School of Medicine, 2006.
Presentations and Testimony
Peter M. Merles, "An Ounce of Prevention ," to the Hearing on Elderly Fall Prevention of the Health, Education, Labor and Pensions Committee, Subcommittee on Aging, United States Senate, June 11, 2002, Washington.
Report prepared by: Mary B. Geisz
Reviewed by: Robert Narus
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe