A Guide to Resources for Older Adults, Family Members, and Caregivers

Navigating aging can pose challenges to older adults, family members, and caregivers.  Health care needs may change, or individuals may want to be proactive in planning ahead so they know what’s available in case they need it.  Having information around various services and resources for older adults can help equip them, their families and caregivers when considering their options for aging in their place of choice, whether at home or elsewhere.  Caring for the health and wellness of older adults not only includes access to medical doctors, but extends to help at home, transportation, social opportunities and mental health. 

It can feel overwhelming knowing where to go for this information.  Where do I start?  Do I go to my Primary Care Doctor? The local senior center?  As a family member or caregiver, how do I know what’s available to support my loved one?

Below, please find information about services available to older adults, what the organizations do, and how to contact them to get the services that are needed.

Getting Started

ASAP (Aging Service Access Points)

Every town in Massachusetts has a designated Aging Service Access Point (ASAP).  The ASAP may not be located in the same town where the individual lives, as they typically cover a region, but a particular agency will have information available in all the towns they cover.  Help in pinpointing your communities’ ASAP can be found here.

What do ASAPs offer?

Options Counseling and Aging Information

Information and referral departments are often the first point of contact for any new client to an ASAP, or for anyone seeking information.  Older adults, families or caregivers can contact their local ASAP for Options Counseling.  Departments may be called Aging Information, Options Counseling, or Care Advice and Planning.  They can offer information about home care offerings and discuss an elderly person’s or caregiver’s specific set of circumstances.  They may also offer consultations on resources apart from home care.  Some topics include caregiver support, elder law, elder housing, geriatric medical care resources, Alzheimer’s disease support and education, health insurance, mental health and wellness, assisted living options, and community/ local resources.  In some cases, case workers or social workers within the information/ referral department can meet with an older adult or caregiver in the home for short-term planning and support.

In-Home Services

Care and services provided in an older adult’s home are primary offerings with ASAPs.  Case Managers conduct home visits with older adults and families and will assess the need for home care services which could include help with housekeeping, home delivered meals (Meals on Wheels), personal care (help with bathing, dressing, etc), Personal Emergency Response System (i.e. Lifeline), grocery delivery, laundry service, companion services, and transportation to the grocery store and to medical appointments.  The Case Manager will determine if the older adult is eligible for services, and if so, the older adult will agree to the services they think would be most beneficial.  From there, the case manager will coordinate those services on behalf of the older adult and their family.  Each ASAP has contracts with elder care vendors to deliver these services.

How do I know if I am eligible for services through the ASAP?

The first step is to request an assessment for services by contacting your local ASAP.  A Case Manager will come to meet with the older adult, their family or other caregivers in their home for free. The Case Manager is assessing the older adult’s needs in terms of aspects of daily living, what support they already have, as well as the support they need.  Because services through the ASAP are subsidized, there are eligibility requirements in terms of income.  Case Managers need to determine that the older adult needs assistance with multiple areas of daily living in order to be eligible for services through the ASAP.  For example, someone who only needs help with grocery shopping, but is independent in all other areas of home life, may not be eligible to receive subsidized home care services.  Click here for more information.

Clients receiving home care services will have a Case Manager on an ongoing basis.  Case Managers conduct periodic home visits and will be a point of contact for the older adult, their family or caregiver.  Case Managers make referrals on behalf of the older adult, and will also communicate with the agencies providing services to ensure that older adults are getting the support they need. .  They also communicate with clients, receive feedback on the services, and communicate with vendors to help ensure adequate service delivery.

Beyond in-home services, ASAPs may be able to offer services that are largely implemented by volunteers and volunteer administration who provide services to older adults in their home.  For example, the Money Management Programs assists older adults who have difficulty maintaining bill payments and budgeting.  Volunteer programs may include social visits, faith-based visits, and escorting for medical appointments.  Contact your ASAP for more information.

Adult Day Health

ASAPs may make referrals to adult day health and these programs may be funded by ASAPs as part of services.  Adult Day Health centers are generally full-day programs (i.e. 8:30 a.m. to 4:00 p.m.), although some may offer half-days.  Clients might attend between 2 and 5 days per week, and some programs offer Saturdays.  Adult Day Health centers may have two different levels of care: one for clients who are more independent and one for client’s who need more hands-on care.  Nurses, social workers, specialists, aides, and other staff implement the day’s activities.  While on-site, clients may have needs met for social activities, meals, fitness, medication administration, healthcare support, and therapeutic activities such as art and music therapy.

An ASAP may be able to help in navigating eligibility for coverage for Adult Day Health, when paid for through an ASAP or by MassHealth.  MassHealth may cover Adult Day Health depending on medical and functional needs, and private pay is an option.  For more information about local specific Adult Day Health programs click here.

Councils on Aging

Councils on Aging are often specific to the town and are a part of town services.  They may offer a social services employee to help with resources and information, such as housing applications.  Some offer health education programs, social events, and groups.  To find the local senior center in your community click here.

Older Adult Mental Health Resources

Elder Mental Health Outreach Teams, also known as EMHOT, is a relatively new program.  It is regionally-based and is not available in all regions on Massachusetts.  Many referrals to EMHOT come from Councils on Aging or seniors centers.  However, individuals can self-refer.  Clinicians work with elders who participate in EMHOT, providing short-term counseling and help with planning to address mental health and wellness for after discharge from the EMHOT program.  Clinicians may assist with long-term planning by connecting with providers and community resources, making referrals, and provide support to staff in the community to promote competency in elder mental health.  For more information, click here.

Some ASAPs have mental health initiatives, programs, or mental health case workers.  Aging Information departments within ASAPs can offer more information about their particular offerings for mental health and wellness.  If an elder has a case manager with an ASAP, the case manager may be able to help navigate any particular services within the ASAP.

Connecting with mental health wellness services over the phone can be valuable when there is an issue of difficulty getting out of the home.  It can also be helpful when a need arises to speak with someone soon.  Some phone lines cater to urgent needs and crises, while others offer a listening ear and help with gathering and processing information

This list includes helplines you and a loved one can call for support.  These do not replace mental health treatment, but can supplement and complement treatment. 

One program that can be particularly helpful for older adults is Call2Talk’s Telecheck.  Learn more here

 

What do I do if I’m worried about my safety or the safety of an older adult?

Elder Protective Services

Protective services departments are part of Aging Service Access Points (ASAP).  They screen reports of elder abuse (physical, emotional, and sexual abuse), neglect by a caregiver, financial exploitation, and self-neglect.  Neglect of an older adult may not always be on the part of a caregiver.  Neglect of self is also reportable for persons over 60 years of age.  When an elder lacks adequate medical care, adequate housing, or basic needs such as food and utilities, Protective Services may assess for risk of harm as well. 

The first point of contact for reporting is the elder abuse hotline.  Reports are then sent to the designated Elder Protective Services agency, depending on the older adult’s town of residence.  Protective services will decide to either screen in and investigate the report, or screen out the report and not investigate at this time. In Protective Services investigates the report and finds there is a concern, resource and care planning may be implemented to help alleviate the concern.  The elderly person’s wishes are to be respected.

For more information about this program or how to call to discuss concerns about the safety of an older adult click here

What if I have questions about my insurance coverage?

SHINE (Serving Health Insurance Needs of Elders)

Health insurance can be complicated.  SHINE counselors work with older adults, people with disabilities, and caregivers to understand and access Medicare and MassHealth options.  SHINE counselors can help in understanding eligibility for certain types of insurance and navigating the applications processes.  They may be able to offer assistance if an individual is at risk of losing benefits or has lost insurance coverage.  A designated ASAP or Council on Aging may be able to offer SHINE counseling directly or refer to a SHINE counselor.  For more information click here.

Senior Care Options

Senior Care Options (SCO) health insurance plans offer health care services that are typically reimbursable by Medicare and MassHealth.  If an older adult chooses to be covered by a SCO, it is typical to go through the SCO plan as a single entity for health care services.  If enrolled in a SCO plan, a care coordinator or care manager, such as a registered nurse, may serve as a contact person to approve services, manage care, and help ensure health care and home care needs are met.  The SCO plan may work in conjunction with a local ASAP for care management, and some SCO plans also cover home care services.   You can contact your designated ASAP (options counseling/ aging information department) for discussion, or contact a SCO plan directly. To learn more click here.