Aging Programs Best Practices


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Enhancing Work Efficiency: Using Technology to Get Reliable Program Outcomes Data, San Francisco, CA

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The San Francisco Connected Program offered by San Francisco Department of Aging and Adult Services (DAAS) provides free computer training in multiple languages to more than 1,000 seniors and adults with disabilities in 55 San Francisco senior/community centers. The administration of online surveys to participants and use of computer tracking software allowed DAAS to obtain accurate data for measuring program outcomes. In the past, consumer satisfaction surveys were distributed and returned in paper form. Use of an online survey tool led to an increased response rate on the survey, which is administered in five languages (English, Spanish, Chinese, Russian and Vietnamese). In addition, computer software is now used to track participants’ online activities at community centers in order to gauge how they are educating themselves about health promotion and economic security issues. The average paper survey return rate was 8.7%; the online survey return rate for FY 2013–14 was 27.6%. Data collected from the software tracking computer usage showed that 11,312 activities were related to economic or health improvement information, which helped answer funders’ questions about computer usage and confirmed that the program helped participants gain information on health improvement and economic security. The total startup cost is $5,197; annual cost is $2,144.

Community Living Program, Michigan

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The Area Agency on Aging (AAA) launched the Community Living Program (CLP) in January 2011 to reduce waitlists by moving from a traditional care-management model of providing a comprehensive, in-home assessment for all individuals (regardless of need or ability to access services) to a tier-based, person-centered model of care management that can serve more people at all income levels. Individuals referred to the CLP begin with a phone consultation. A care manager develops a care strategy plan based on a client’s needs and helps the person access services. A care manager visits clients at home who cannot be assisted by phone. Nursing home clients receive traditional care management services, which include a comprehensive assessment and ongoing care coordination. The AAA also created partnerships with Section 202 senior housing coordinators and outreach organizations to work with a care manager to authorize services for older adults with whom they have contact. This reduces the number of home visits by AAA’s care manager while increasing the number of clients served. Actual costs included one part-time care manager position at $32,000, and $2,000 to develop and print program brochures. LP reduced the waitlist for traditional community care management services by 79% and increased the number of clients served by 47% over the same period.

Volunteer Handbook, Loudon County, VA

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The Loudoun County Area Agency on Aging (AAA) Volunteer Handbook was designed to enhance the management of volunteers and follows the recommended best practice of the Corporation for National and Community Services (CNCS) Senior Corps Handbook. The investment in a comprehensive volunteer handbook greatly contributed to the 117% (284 to 618) growth of the AAA volunteer corps, and the volunteer satisfaction rate rose from 85 to 97% in meeting the growing demands for programs and services in the Loudoun County community. The most salient reason for implementing a Volunteer Handbook into Orientation is that it provides the opportunity for volunteers to “self select” out and gives managers the option to select appropriate candidates. Yes! It gives the Manager confidence that it’s okay to say “No” if the volunteer does not “fit” the selection criteria. Remember, good “fit” results in good service and volunteer satisfaction. View Volunteer Handbook (pdf)

Moodle Volunteer Development System, Ventura County, CA

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State Health Insurance and Assistance Program (SHIP) counselors volunteering with Ventura County Area Agency on Aging (VCAAA) often faced a wait time and had to undergo a complex, time-consuming training process before going out into the community to help people with Medicare and Medicaid problems. To remedy this situation, VCAAA set a goal to reduce the volunteer dropout rate by 50 percent. To meet this goal, VCAAA sponsored the development of an online, web-based program that provides volunteer training as well as access to necessary documentation and videos. Volunteers can communicate privately online with their mentors during the training and can track their time. The system provides counselors a secure learning environment that is available at any time or from any place.

Outdoor Spaces and Building

Walk Wise, Drive Smart, Hendersonville, NC


Based on community feedback and input gathered from partners and advisory committee members, staff developed an action plan with three main objectives: (1) Provide educational workshops and a series of walking audits of neighborhoods in Hendersonville; (2) Gather extensive community feedback through surveys and interviews; and (3) Identify features needed to implement a pedestrian safety plan that is responsive to the specific needs of residents in Hendersonville

Safe Routes for Seniors, Goleta, CA


Safe Routes for Seniors, COAST's project, is a highly replicable model that pioneered the approach of bringing together stakeholders, finding out their needs, and creating useful maps based on findings. prioritized projects based on pedestrian counts and senior input, is a novel resource for both Goleta and eastern Goleta Valley as neither has a master pedestrian plan.

Revitalizing a Treasured Public Space, Macon-Bibb, GA


Revitalizing a Treasured Public Space is improving the park and the roads adjacent to it. Among the enhancements thus far include: (1) The addition of prominent, ADA compliant gate­ways help to define the park’s boundaries and entrances; (2) Wider, smoother sidewalks were installed to bet­ter serve older pedestrians and people pushing strollers; (3) The park has new benches, seating areas (many made of stone) and a drinking fountain; (4) The park’s interior is now vehicle-free and accessible routes into the park have been added; (5) Construction of a modern roundabout has helped make nearby streets safer by slowing fast-moving traffic around the park. Cost included thousands of volunteer hours, $2.5 million spent on the park so far (from 2012 to 2015), funded by community grants and donations.

Making Streets & Sidewalks More Walkable, Washignton, DC


The Block-by-Block Walk program by target­ing micro-neighborhoods of about 2,000 residents. volunteers walk within a three to five block perimeter, most remaining in their immediate neighborhoods. They travel routes they know well and consider whether pedestrians can safely access needed services and amenities. By using the city’s DC311 smartphone app, which was launched in 2011, the Block-by-Block Walk volunteers can report problems directly to the District’s Department of Transportation (DDOT). The Office of Unified Communication staffs the 311 call center and sends reports to the district government agency for completing requested repairs.

Increase Park Us​age, New York City, NY

59 initiatives - DFTA, the Parks Department, and NYAM have worked closely to increase seniors' usage of NYC parks. The Parks Department has created an entire page devoted to resources for seniors: seniors. BeFitNYC is a search engine on the Parks website that helps New Yorkers find free and low-cost fitness opportunities offered by the Parks Department and partners. One of the features of the search engine is the ability for users to narrow the results by age (e.g., child, adult, senior). Senior Swim hours have been designated at 15 public pools citywide, which is double the number of pools in the original pilot program.


Addressing Transportation Barriers for Older Adults and People with Disabilities, Atlanta, GA


Best practices were shared by Atlanta Regional Commission (ARC) staff, including how the ARC uses technology and outreach to share transportation information and resources.

Pennsylvania Free Transit Program, PA


Funded through the Pennsylvania State Lottery, Pennsylvania Free Transit Program allows adults 65 and older to ride local fixed-route buses for free during all regular operating times, including holidays. The Pennsylvania departments of aging and transportation, seven other state agencies, local governments, and public transportation operators coordinate this program.

Educating Older Adults About Using Public Transit, Edmonton, Alberta, Canada


The education programs, which are free to participants, are administered by one full-time staff member at Edmonton Transit along with a seasonal summer program coordinator. Edmonton Transit covers all costs for the trainings. 8 different programs.

Better Benches and Bus Stop Shelters, New York City, NY


Senior centers throughout the city suggested places where a bench would be useful and the DOT studied other areas with a high concentration of older people, such as neighborhoods where many are aging in place. The department also flagged locations within a quarter-mile from a hospital, community health center or municipal facility. In order for the shelters to serve everyone, their design takes into account mobility issues, such as the need for a wide-enough entry and exit to accommodate people using wheelchairs.

Benches, a Bus Livability Grant from the Federal Transit Administration, funds 80% of the $2.4 million cost. The New York City DOT covers the remaining expenses (approximately $600,000 so far) to install and maintain the benches.

Transportation Reimbursement Escort Program, San Bernadino, CA


The senior is responsible for finding their own driver to take them wherever they need to go. They submit a claim to DAAS who certifies it and sends it to the Senior and Disabled Fund for payment. At the end of each month DAAS reimburses the Senior and Disabled Fund for the total cost of the month’s claims. Operated by DAAS in conjunction with the Senior and Disabled Fund, a local non‐profit.

Accessible Dispatch, New York City, NY

Accessible Dispatch compensates drivers for their travel to a pickup location, so passengers pay only the metered taxi fare. In addition, TLC was recently authorized to increase the number of medallions for accessible taxicabs by 2000. All drivers of wheelchair accessible taxicabs are required to participate in the Accessible Dispatch program, which has completed over 18,000 trips since its launch. 59 initiatives. After a 2-year pilot program, the City's Taxi and Limousine Commission (TLC) launched "Accessible Dispatch" in September 2012.

Market Ride, New York City, NY

Market Ride uses school buses during off hours to take seniors from senior centers to supermarkets and farmers’ markets that have a greater array of fruits and vegetables than their smaller, neighborhood stores. School buses are also used to take senior center members to recreational facilities, museums, Broadway shows, and a host of other venues. Market Ride began as a pilot program in Brooklyn in the 2008-2009 school year and is now available to senior centers in all five boroughs. Since October 2012, 13 senior centers and 3 NORCs have requested buses to transport seniors to markets, and 52 trips have allowed 1,333 seniors to participate in this service. Buses depart from the centers in the mornings and return to the center just before lunchtime. 

59 initiatives. There are no direct costs for the program. New York City’s contract for school buses covers driver salaries (drivers are paid for “down time”) and fuel costs.

"100 Key Stations" Initiative, New York City, NY

The Metropolitan Transportation Authority (MTA) is making 100 centrally located stations, or "key stations," accessible by 2020. As of August 2012, 77 stations were accessible. In addition, riders can subscribe by borough or station to get alerts when an elevator or escalator stops and resumes working. 59 initiatives.

Subsidized Taxi Smart Card, New York City, NY

A collaboration between DFTA and the Mayor's Office for People with Disabilities (MOPD), the Taxi Smart Card Program is a pilot project that began in November 2012. The program serves seniors and disabled New Yorkers by providing a pre-loaded $100 “debit card” to be used in taxi cabs and livery cabs. 

59 initiatives. Out of pocket cost for enrollees is $12.50 and the program contributes $87.50, and the card can be reloaded 4 more times at a cost of $12.50 for each reload, saving participants $437.50 in travel expenses. The program is funded through the federal New Freedom grant program administered locally by the City's Department of Transportation (DOT).

Bus Coin Project, Akita, Japan


In Akita, older people over the age of 68 are entitled to ride a bus at an affordable price of 100 yen to make it easier for them to go out and participate in social life. Riding on buses is central to their daily life. Furthermore the city provides alternative transportation in the case where bus routes have been discontinued due to unprofitability.

Cyclopousse, Lyon, France


Cyclopousse, an “associative public private” partnership with the region of Lyon, has implemented a transportation service that is accessible and tailored to older people. The “Cyclopousse” is an innovative pedicab that can transport two people to the destination of their choice in a perimeter of 500 meters to 1.5 kilometer. Based on a proximity approach, it provides a friendly, comfortable and secure means of transportation particularly for whom inadequacy of transportation is often synonymous with isolation.

Get a Ride Guide, Riverside County, CA

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The Riverside County Office on Aging developed the Get a Ride Guide in partnership with 23 organizations. Guide helps navigate a complicated transportation system, particularly as they transition from driving to relying on assisted transportation. The Guide goes beyond the traditional contact directory, providing detailed information on transportation options and consumer information on topics such as travel training, qualifying for a restricted license and staying on the road to help readers remain independent, self-sufficient and connected to their community.

Saturday Service 4 All, Virginia

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Mountain Empire Older Citizens, Inc. (MEOC) began Saturday transportation for individuals with disabilities and seniors through the assistance of a variety of community partners including the local community services board, behavioral health providers, and the Department of Veterans Affairs. This service, provided by MEOC’s transit department, offers a coordinated system of public and human service transportation with additional support services including passenger attendants, shopping assistance and mobility management.

Bexar Area Agency on Aging Mobility Management, Texas

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“Call A Ride for Seniors’’ coalition, which involves four volunteer-driver nonprofits providing escorted transportation; and conducting and presenting independent research at local and national conferences on gaps in service areas, senior-dense areas in proximity to services, and referrals for transportation and mobility aides by zip code to demonstrate high-need areas. The program also developed a guide for older adults and people with disabilities on getting around Bexar County and the surrounding Alamo region; and writes and distributes the “Alamo Area Accessible Transportation and Mobility” monthly e-newsletter.


Grandfamily Housing, Bronx, NY


WellElder Program, San Francisco, CA


There is one on-site service coordinator and one nurse health educator in each building.

Rent-A-Kid, York County, PA


Once matches are made, the older adult is notified and responsible for contacting the assigned youth to discuss details, including specifics of the job, when they are needed, and the rate of pay for the job. The recommended rate of pay is $5 an hour, enough to give young people some extra pocket money, but the youth and the older adult may negotiate a higher rate depending on the complexity of the task and the ability of the older adult to pay.  Issues include liability and minimum wage.

Lifetime Community, Marbleton, GA


According to the Mableton code, single family homes must be built so that: (1) One zero-step entrance shall be provided at the front, side, or rear of the principal building; (2) All doors on the main floor of the principal building shall provide a minimum of 32 inches of clear passage space; (3) One accessible full bathroom providing wheeled mobility shall be provided on the main floor of the principal building. Blocking for grab bars shall be provided at a minimum; and (4) One bedroom or room easily adaptable to a bedroom shall be provided on the main floor of the principal building.

Making Big Sense of Small Homes, Portland, OR


Accessory dwelling units (ADUs) are small, independent housing units created within single-family homes or on their lots. reduced (or "waived the largest") municipal fees and adjusted the city's zoning codes to make it easier for a homeowner to add an ADU to his or her property. An overriding reason for the change: to help residents age in place. The cost of building ADUs is borne by the property owner.

Living Together Benefits Young People and Old, Lyon, Rhone-Alpes, France


At a dozen independent living residences that serve older adults, college students are invited to move in and pay discounted rent in exchange for socializing with the building's older residents. Another program helps fill rooms in the houses of older adults with empty nests. Approximately 1,000 apartments in the 12 city-owned residences for older people that are taking part in Lyon's program. About 100 apartments in these buildings are set aside for the students. Both older and younger people confirm that intergenerational living is an enriching experience.

Design for a Lifetime: Preparing Your Home for Successful Aging, New York City, NY

The New York Public Library hosted an event which featured a panel discussion with experts from the AIA Design for Aging Committee. 59 initiatives.

Senior Citizens Homeowner Assistance Program (SCHAP)New York City, NY

Administered by the Parodneck Foundation with funding provided by the City's Housing Preservation and Development (HPD), the Senior Citizens Homeowner Assistance Program (SCHAP) has made over $15 million available to older New Yorkers since its inception in 1998. The program assists senior homeowners with house repairs and foreclosure prevention, ensuring that older and homebound homeowners can remain in their homes. 59 initiatives.

Contractor EngagementNew York City, NY

New York City's Department of Consumer Affairs (DCA) has a flyer, Learn Ways to Make Seniors’ Homes ‘Age-Friendly’, that is available in English and Spanish and continues to be available in their Licensing Center as a resource for home improvement contractors. In 2011, DCA mailed the flyer to more than 12,000 home improvement contractors renewing their licenses. 59 initiatives.

Rent Increase Exemption programNew York City, NY

The Senior Citizen Rent Increase Exemption Program (SCRIE) provides eligible older New Yorkers with an exemption from some or all increases in rent. The City successfully transferred responsibility for administering SCRIE from DFTA to the Department of Finance (DOF) in 2009. Partnering with DOF, DFTA staffs an on-site walk-in center to assist with applications. Customer service has improved through the walk-in center, improved language access, a dedicated customer service group within the Exemptions division, and the publication of a comprehensive SCRIE guide. The processing time for SCRIE approval or denial has been reduced to 30 days. 59 initiatives.

Free A/CNew York City, NY

Due to fluctuations in funding, the number of air conditioners distributed to at-risk New Yorkers who meet low-income guidelines and suffer from a documented medical condition that is exacerbated by heat has varied from a high of 1,700 in summer 2010 to a low of 391 in summer 2013. DFTA works with its senior centers to operate "cooling centers" in conditions of extreme heat, and the City's Department of Health and Mental Hygiene (DOHMH) has distributed educational materials (in English, Spanish, Russian, and Chinese) with tips for older adults on “keeping cool” to senior centers and to more than 16,000 homebound seniors and adults through DFTA’s long-term care unit. 59 initiatives.

Housing and Supportive Services for Older Adults, Toledo, Ohio

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The National Church Residences (NCR) organization and the Area Office on Aging (AOoA) of Northwestern Ohio have worked together for more than a decade to provide supportive services and quality care for low-income seniors and disabled adults; NCR managed several housing properties for AOoA. But in 2010, after an accident destroyed a historic housing complex in downtown Toledo, AOoA convinced NCR to work with them to rebuild and rethink the facility. The resulting joint venture funded and created a 54-unit facility known as the Renaissance Apartments.Thanks to the collaboration, some of the community’s most vulnerable citizens have access to quality care and supportive housing. NCR invested more than $10 million in renovation of the facility, which was originally built in the early 1890s. AOoA provides services (such as daily meals, home-care waiver services, information and assistance and service coordination) to residents.

EZ Fix Program, Maine

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The EZ Fix Program helps seniors and adults with disabilities remain safely in their homes by providing minor home repair, housekeeping, and in-home technology training and services throughout rural Eastern Maine. Initially, Eastern Area Agency on Aging (EAAA) recognized that low-income seniors were struggling to keep their homes repaired and established a volunteer-based program to address these needs. When it became apparent that seniors also faced challenges keeping their homes clean, housekeeping volunteers were recruited. Most recently, the Home Technology Service Program, which offers assistance with computers, phones and other home technologies, was added in response to client requests. last two years, 1,277 seniors and adults with disabilities have been able to remain in their homes. More than 500 home safety audits have identified and remedied numerous fall hazards. Housekeeping services have reduced incidence of filth-related illnesses. As a result of performance, the program has attracted more than $245,000 in private grant funding. Total annual operating cost is $84,039. This scalable program is easily replicable by organizations with a strong volunteer base and someone to coordinate activities. However, volunteer recruitment in rural areas can be challenging.

Social Participation

Síclovía, San Antonio, TX


Hosted by the YMCA of Greater San Antonio in partnership with the City and other community partners, Síclovía currently closes two miles of streets to automobile traffic to host a free street party and health fair, twice a year in the spring and fall. Along the route, the YMCA and its partners, including the AWLW program, host what are known as reclovías—areas where attendees can stop to watch demonstrations, participate in physical activities, or learn more about their health. The first Síclovía attracted a little over 10,000 participants, but most recently drew over 70,000

Community Gardens and Senior Health, Philadelphia, PA


To share lessons from NSC’s garden project and others, GenPhilly developed a toolkit.

Promoting a Positive Story on Aging, Manchester, England


130 volunteer "Culture Champions" work within their networks and com­munities to promote Age-Friendly Manchester's cultural activities and events, such as concerts, tours, an older people’s choir (pictured), creative writing classes, play readings, live music and an array of intergenerational projects. Research: each Manchester-based Culture Champion engages more than 20 other older residents, helping them stay connected and involved in the community.

Making a City’s Streets Safer and Sociable, Brownsville, TX


At least four times a year, miles of streets in downtownBrownsville, Texas, are closed to cars and trucks so residents (and, increasingly, visitors) can gather to bike, walk, jog, dance, socialize and simply have fun.

Seniors Partnering with Artists Citywide (SPARC), New York City, NY

SPARC places artists in residence at the City’s senior centers, where they provide arts programming to older adults. Currently, there are 50 artists working at 48 centers in a variety of media, including dance, theater, visual arts, music, photography, and writing. 59 initiatives.

Creative Aging art courses, New York City, NY

The New York Public Library (NYPL) has been offering Creative Aging art courses at 15 libraries in Manhattan and the Bronx. Classes include quilt-making, music, drama, creative writing, and portraiture. Creative Aging art classes will continue to be offered through November 2013. The NYPL received private grants to increase technology courses and programming for older adults, and the NYPL Tech Connect staff, who focus on computer training, has developed curricula for several computer classes targeting those over 50. 59 initiatives.

Senior Program on the Move, unlisted location


Project includes physical activities like senior gymnastics +50 and some specific activities such as hiking, walks, visits and participation in various social events. The main objectives of this project are increase social interaction, the decrease in isolation, increase levels of independence and autonomy, the use of free time, the promotion of wellness (healthy lifestyles) and prevention of falls.

Walker Rally, Oslo, Norway


In conjunction with the UN – International Day of Older Persons, 1st of October, the department for primary health and social affairs organize a week of activities for the elderly, culminating with the celebration of the international day of older people. One of the most popular initiatives, organized for the second time on the 23rd of September, is the “Walker rally”, where prizes are awarded for completion of a certain distance and also for the best decorated walker. It is also possible to take part using walking sticks and wheelchairs.

Novel Seniors, Bangor, ME

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In 2008, Eastern AAA launched the Novel Seniors book club to connect older adults and the homebound with a social and intellectual activity. Annually, about 24 book club members read and discuss a “book of the month.” Homebound participants call into meetings. A book club participant writes and publishes reviews of all the books read in a bimonthly newsletter that is distributed to 3,500 clients. Several times a year, book club members meet with an equal number of students from a local high school during a senior lunch. Discussions vary widely, depending on the books read, and may range from death and dying to past practices of racial discrimination. Book club members select the books they want to read and discuss. The cost to run the program is $2,500 annually for the books and technology; famous local writer financially supports the program.

Community Breakfast, Rochester, NY

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Breakfast Shoppe is a Monday through Friday 7:00-9:00 a.m. Community Breakfast Program at the Rochester Senior Center run jointly by the FRIENDS of the Rochester Senior Center and Rochester Lions Club. It operates solely with volunteers who do the purchasing, cooking, serving and clean-up. The Senior Center, housing a commercial kitchen, made quick arrangements with the Rochester Lions Club and the Rochester FRIENDS of the Senior Center non-profit groups, who both agreed to share the operation of a new breakfast program at the Senior Center, utilizing volunteers, with the proceeds split between the two organizations, and ultimately given back to the COA/Senior Center for its operation.Historically, numerous community folk, namely senior citizens and many of them male, would gather for hours at this site for a bite of breakfast and coffee, but also for the opportunity to socialize and chat or debate about local happenings and state and world news. Many of these participants would never set foot inside the senior center, just feet away from the restaurant. At present time, a total of 25 volunteers work the program. In addition, there are up to 10 senior volunteers who participate in the Town’s Property Tax Work-Off Program. The Work-Off Program allows a qualified town senior to give $750 worth of service (based on $8.00/hr.) a year in order to receive a $750 tax credit on their property taxes. The COA has tripled its annual unduplicated participation count overall, and it has doubled the number of male attendees within the unduplicated count.

Respect and Social Inclusion

Dementia-Friendly Businesses Watertown, WI


Dementia-Friendly Businesses educates and trains businesses on what they can do to enable customers with dementia to remain a vital part of the community. Funding and in-kind donations for the program are generously provided by the Lutheran Home Association

Age-Friendly Local Business Initiative, New York City, NY


This educational outreach campaign provides advice on how to attract and better serve older customers at low or no cost. The initiative’s educational and self-assessment materials provide guidelines and tools to make a business more accommodating to older adults and help small businesses identify areas for improvement, such as website design, lighting, or customer service. Businesses that participate in the initiative receive an age-friendly decal for their storefront and are included on lists promoted to older consumers so that residents are aware which retailers are committed to being age-friendly. The initiative has successfully signed up over 1,000 businesses citywide to participate since 2010.

Forming a Business Advisory Council, New Jersey

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Community Volunteers of Central Jersry (CVCJ) formed a Business Advisory Council (BAC) comprised of 12 – 15 local professionals who work in businesses with a similar demographic to the people we assist, i.e., senior citizens, caregivers, individuals with dementia, adult children caring for parents, etc. The BAC was formed in 2009 and will continue in 2013.

Intergenerational Learning Center @ High School, Swampscott, MA


The new senior center, which has its own parking lot and entrance, shares the high school’s equipment and facilities, including the gymnasium, dance studios, a pottery kiln, and the computers.

Age to Age Kindergarten, Coffeyville, KS


This all-day kindergarten class operates right in the middle of the nursing home, partnering children with elders, called “Grandmas and Grandpas”, to read, play, exercise and learn throughout the day.

Building a Playground for All Ages, Wichita, KS


Community members wished they had easy access to a safe and attractive place where they could spend time outdoors with their grandchildren, get some exercise and socialize with other adults. The city of Wichita agreed to convert the empty lots, which were eyesores the city was spending money to maintain, into a half-acre public park. Installation of the trails, exercise equipment, drinking fountain, benches, signage and fencing cost about $22,000 and were paid for by AARP Kansas.

Helping Make Dreams Come True, Taipei City, Taiwan


Helping Make Dreams Come True is an annual motorcycle tour around Taiwan. In its inaugural year, 2007 the average age of the 20 individuals chosen: 81. All but three of the "Grandriders" finished the trip, traveling 730 miles in 13 days and sparking a movement that became known as Bulao, which translates to "forever young." Other activities include: Bulao Baseball League, Bulao Soldiers program, Bulao Broadway show.

Intergenerational Conversation Project, Marin County, CA


Pre‐med students are matched with older adults living in neighborhoods close to campus and other nearby communities for home visits and get‐togethers. ICP expands the social network of students and elders, develops the leadership skills of students, and addresses the shortage of professionals in geriatric care. ICP is led by Dominican University of California and Marin County’s Area Agency on Aging in partnership with other academic, national, and home‐ and community based organizations serving older adults.

Telephone Reassurance Program, New York City, NY  

117 community-based senior center providers participated in Department for the Aging’s telephone reassurance program and made 41,947 calls to homebound older adults in their respective communities. 59 initiatives.

Friends in School Helping Program, Charlottesville (and surrounding counties), VA

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Jefferson Area Board for Aging’s Friends in Schools Helping (FISH) program, a volunteer tutor-mentor program in the local schools, is a tangible example of an intergenerational approach to meeting needs in the community. 

Project CARE (Caring Actions Responding to Elders), Los Angeles, CA

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Project CARE provides food, clothing, personal hygiene items, books, craft materials and other gifts to seniors during the holiday season. Project CARE identifies people to receive gifts with the help of senior center care managers. The project team is composed of volunteer city staff who recruit employees as sponsors and match them with seniors. Volunteers also recruit more than 20 “ambassadors” from within the city’s 40 departments and from the community to help collect, inventory and distribute all gifts.

Livin' the Good Life, Beverly, MA

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Livin' the Good Life is a local cable television show aimed towards providing seniors with information that they might otherwise not receive or learn. The show is hosted, directed and filmed by senior volunteers. The Beverly Council On Aging Assistant Director is the Producer. Most episodes consists of interviews with local professionals that address topics that are of significance to seniors.

Mosaic Elder Refugee Pre-Literacy Program, Arizona 

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To address the need for pre-literate English education among elder refugees who must learn a sufficient amount of English in order to pass the U.S. citizenship test, the Mosaic Elder Refugee Program created a pre-literacy program, found established curricula (the English Pre-Literate Program by Cielito Brekke), recruited volunteer teachers and coordinated with Mosaic case managers to identify participants. The pre-literacy program began with 88 students meeting twice weekly during 10-week-long sessions held at three sites. At the end of each 10-week session, students are evaluated on their progress and then are either referred back to their case managers, continue for an additional 10 weeks or graduate to an ESL class.

Senior & Disability Survival School and Senior & Disability University, San Francisco, CA

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To assist seniors and ensure local officials are considering their interests and concerns, Department of Aging and Adult Services hired a nonprofit agency called Senior and Disability Action (SDA) to develop an Empowerment Advocacy program that includes two components. Senior & Disability Survival School (SDSS) provides participants with information and contacts needed to gain access to health, housing and other support services. Senior & Disability University (SDU) offers formal training on influencing civic and political change. Because seniors or adults with disabilities in San Francisco may come from immigrant, LGBT or disabled communities as well as a variety of different ethnic/racial backgrounds, classes are taught with a diverse audience in mind. One semester might target Russian immigrants living in the Sunset District; another may focus on homeless seniors living in the Central City. Having developed advocacy skills, graduates of SDSS and SDU participate in public hearings on a variety of issues such as free public transportation for seniors and adults with disabilities. The curriculum developed for the two schools can be shared with other organizations via email. The cost of staffing can further be reduced with the assistance of committed volunteers. Annual budget for SDA Empowerment Advocacy is $178,850.

Unseen Images, Untold Stories: Using Photovoice to Capture the Lives of LGBT Elders, Northeast, FL 

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“Unseen Images, Untold Stories” is an exhibition by lesbian, gay, bisexual and transgender (LGBT) elders in Northeast Florida. LGBT elders confront a “double whammy” in facing challenges associated with aging while being vulnerable because of their sexual orientation and/or gender identities. The exhibition is based on PhotoVoice, a grassroots approach that uses photography to initiate community conversations on key issues. The exhibit, supplemented by audio-recorded stories of six participants, is designed to increase community awareness; inform elected officials, policy makers and the general community; and encourage support of laws and services to help LGBT elders age with dignity and independence. Cost is $10,994.

City of Los Angeles Senior Art Exhibit, Los Angeles, CA

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The Los Angeles Department of Aging developed a partnership with the Los Angeles City Department of Cultural Affairs that manages the City’s galleries, and the University of Southern California School of Fine Arts to create an annual Citywide Senior Art Exhibit. Held at the Bridge Gallery in the Los Angeles City Hall, the exhibit celebrates Older Americans Month. The event, starting with 40 artists in 2004 and growing to 80 in 2010, features art works by senior amateur artists who present various mediums, including painting, photography, poetry, fabric arts and jewelry. The citywide showing attracts more than 10,000 people annually, many of whom contact the Department of Aging with positive feedback. Cost is $6,000.

Civic Participation and Employment

Keeping Older Employees on the Job, Stoke-on-Trent, Staffordshire, UK


Keeping Older Employees on the Job provides 1) flexible work arrangements to help employees maintain work-life balance, especially those who need to provide care for their spouse or parents; 2) free 24/7 help (through the "Carers Emergency Scheme") is offered if an employee who is a caregiver has a personal emergency and needs someone to step-in and assist his or her care recipient; 3) workplace training about topics including fall prevention and dementia awareness; 4) lifestyle education for employees with health conditions such as diabetes or heart disease; and 4) free 20-week physical fitness program and free access to the City Council's sport and leisure centers. Program funded by a €1.1 million grant (approximately $1.6 million U.S.) from the European Union's Program for Employment and Social Solidarity.

Building Bridges Across Age and Culture, Philadelphia, PA


Project SHINE: Students Helping in the Naturalization of Elders. The Temple University program pairs student volunteers with elderly immigrants in center-city Philadelphia to help ease their transition to a new culture. At local ethnic-based community organizations, senior centers, churches, temples and coffee shops, Project SHINE volunteers can be found teaching conversational English, life skills, citizenship preparation and health literacy skills to immigrants and refugees, who gather to socialize, enjoy a hot meal, grab a take-home snack, or receive help with the myriad problems such newcomers typically face. major support from the Corporation for National & Community Service, the MetLife Foundation and the New York Life Foundation.

Success Mentor Initiative, New York City, NY

Department for the Aging (DFTA) has partnered with the Success Mentor initiative, which connects mentors to students who are chronically absent in an effort to improve attendance. In 2011-2012, DFTA recruited 10 older adults to serve as Success Mentors in 4 schools, where each mentor was matched with 15-20 mentees. At the end of the 2011-2012 school year, the percentage of chronically absent students declined on average by 50%. In 2012-2013, DFTA increased the number of mentors to 24 placed in 7 schools. 59 initiatives.

TimeBanksNYC, New York City, NY

TimeBanksNYC is an online registry where New Yorkers can sign up to assist older adults with errands and other tasks; likewise, older adults can offer their time and talents. For every hour that a participant provides a service for another member, s/he earns a time credit that can be redeemed for services from other members. Exchanges include teaching drawing classes, language tutoring, and cooking meals. Since launching in 2009, TimeBanksNYC has registered almost 2000 members. 59 initiatives.

Equal Exchange TimeBank, NE Vermont

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Equal Exchange TimeBank, modeled after TimeBank USA, allows members to post a need they seek to fill or search member posts to find qualified volunteers. Volunteers bank their hours served, earning “time dollars” toward a need they may have or to pass on to someone in need; everyone wins!

Foster Grandparent Program, New York City, NY

Foster Grandparent Program pairs older adult volunteers with at-risk "grandchildren" who they help with developmental and learning tasks. 59 initiative.

Leeds Older People’s Forum, Leed, UK


The Forum supports its members and ensures the voluntary sector is involved in planning, developing and managing services for older people in Leeds.

Legacy Corps: Support for Veterans & Military Families, San Diego, CA

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County of San Diego, Aging & Independence Services (AIS) was approved for 30 Corps volunteers dedicated to supporting the needs of military and former military personnel. Volunteers—who range from younger students and active-duty military to retirees—commit to 450 hours of service in a 12-month period in exchange for a monthly living allowance and college tuition assistance. Legacy Corps provides one-on-one support and respite, as well as connections to a variety of available community services, to family caregivers of military personnel.

Los Ancianos: Seniors Serving Seniors, Maricopa County, AZ

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Los Ancianos: Seniors Serving Seniors program addresses these challenges using 40 AmeriCorps members age 55 and older, and supporting volunteers to provide health promotion activities at senior centers, and augment home and community-based services provided by the AAA and its partner organizations. AmeriCorps members receive training and guidance from the AAA and partner staff in coordinating health promotion activities, including exercise, Matter of Balance and Chronic Disease Self-Management Program classes, health screenings and presentations for nearly 200 participants at 10 senior centers in rural, minority and low-income areas of Maricopa County. They also provide informal, in-home support to more than 900 seniors and adults with disabilities, and deliver supportive services to some 400 individuals.

Senior Job Club, Michigan

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Recognizing the gap between existing computer training and job placement services for unemployed and underemployed seniors, Region IV Area Agency on Aging developed the Senior Job Club. The project helps seniors return to the workforce and achieve financial stability by: (1) increasing employment skills through a six-week job search skills training and one-on-one coaching, (2) increasing education and work skills through computer technology training and (3) increasing employment through on-the-job training. United Way funded the first five years of the program and has committed to funding three more

Workforce Academy for Youth, San Diego, CA

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Annual costs for 20 youth and 20 Life Skill Coaches: $210,000 Workforce Academy for Youth (WAY) is a groundbreaking intergenerational program that utilizes the strengths of older volunteers as Life Skills Coaches in mentoring youth ages 17-21 who ‘age out’ of the foster care system. The County of San Diego implemented WAY in September 2006 to provide workforce experience to youth transitioning from the foster care system to self-sufficiency. The mission is to give foster youth the opportunity to learn and gain work experience to prepare for a county position or equivalent job, and/or to encourage them to continue their education. WAY unites older adults with youth to support the acquisition of work and life skills in a six-month paid internship program that provides employment, training and mentorship. After six sessions, the graduation rate is 89%. Of those who graduated, 89% were hired to continue working in County departments after graduation and 26% of those who were not previously enrolled in school registered for college

Communication and Information

Finding a Place of Their Own, New South Wales, Australia


Mostly retired men from all walks of life can gather to socialize and talk while working on practical building and woodworking projects. They open up about their lives, their relationships, their health. They build friendships and trust. Men's sheds usually charge a modest annual membership fee (from roughly $4 to $20 in U.S. dollars) and many sheds receive funding from a mix of nonprofit and local or federal government grants. Today there are hundreds of men's sheds worldwide, mostly in Ireland, the United Kingdom and New Zealand, with a handful of others in Denmark, Sweden and North America.

Books-to-Go/Books-ByMail, New York City, NY

Books-to-Go, a program that circulates reading and viewing materials to older adults at over 140 sites; and Books-ByMail, a program that supplies library materials to over 300 homebound Brooklyn residents who have visual and/or physical disabilities—these services are free of charge, and anyone interested in these services can fill out an application online. 59 initiatives.

Health Insurance Information Counseling and Assistance ProgramNew York City, NY

Department for the Aging also makes a Complete Guide to Healthcare Coverage for Older New Yorkers [published in English, Spanish, Russian, Chinese, and Korean] widely available through the agency’s website and other distribution points. HIICAP maintains community sites, conducts Medicare orientations, and advertises for the annual Medicare open enrollment period. 59 initiatives.

Letters to the Editor, Louisiana

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Submitting a well-written Letter to the Editor is an excellent way to gain exposure for your program. There is no cost involved, and it has proven to be a very effective method for obtaining highly desirable volunteers. Not everyone who picks up a newspaper reads the Letters to the Editor, but those who do are generally well-educated and interested in their community and the world at large. They are often “doers.” These are just the type of person you want as a volunteer for your program.

Economic Security Project for Cleveland Seniors, Cleveland, OH

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Low-income seniors face a range of economic challenges, any of which could tip them deeper into poverty. While many programs offer help, accessing and navigating them is often difficult. The Economic Security Project for Cleveland Seniors, a comprehensive and personalized model that Western Reserve Area Agency on Aging incorporated into their Aging and Disability Resource Network in 2010, fulfills the need for hands-on assistance and individualized economic case management. Participants receive a financial assessment and an individualized economic action plan, and are assigned to one or more partner agencies that can help them reach their program goals. Ongoing case management and follow-up contact with the client and partner agencies ensures service delivery and that progress is being made to improve the client’s economic security and quality of life. Participants experienced an average increase in income and/or decrease in budget expenses of $146 per month or $1,752 per year. Results show an average movement of 8.6% toward the Standard of Economic Security for a client. Eighty percent of clients who completed the program have seen a quality of life improvement. Customer surveys report 84% satisfaction. Development and implementation totaled $79,941.

Economic Security Initiative, Cook County, IL

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Through ESI program, AgeOptions provides financial counseling to eligible participants age 55 or older with an income at or below 250% of poverty ($27,925 for individuals and $37,825 for couples). Partnerships with organizations that have expertise and experience with the special challenges to economic well-being allow counselors to assist participants’ needs related to housing, finances and debt management, health, legal employment, consumer protection and public benefits. Counselors follow up to help participants solve problems and respond to barriers, such as public benefits denials. AgeOptions used the Illinois’ Elder Economic Security Index to develop this initiative and uses it to benchmark progress toward economic security. more than 440 older adults received counseling through ESI with more than 630 applications filed on their behalf for public benefits programs. Participants have reduced their monthly expenses, increased their spendable income and gained confidence. Nine older adults volunteered more than 600 hours to ESI, providing counseling and database development services. Annual cost is about $50,000 and funding supports counselors at AgeOptions.

Make Medicare Work Coalition, Cook County, IL

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The coalition works to ensure maximum coverage for those at risk of being overlooked and to help vulnerable groups understand their options as they become available. MMW also bolsters the capacity of community agencies by providing current information, understandable materials, training, technical support and coordination with other agencies. MMW also trained 174 new professionals from 60 organizations. The coalition’s listserv now includes 660 people representing more than 250 organizations, including local, state and federal agencies; social service and health care providers; advocates; and a variety of community-based organizations. A conservative savings estimate from these programs is more than $35 million.

Retirement Options for Persons with Disabilities, Carroll County, MD

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The Carroll County Bureau of Aging’s Senior Inclusion Program (SIP), which provides retirement services for 12 older adults with developmental disabilities in a senior center setting, formed a unique partnership with the Carroll County Arts Council and the ARC of Carroll County. The partners created an Art Collaborative that encourages dialogue between local service providers and educates younger adults with developmental disabilities about retirement programs provided by senior centers. This year, the Art Collaborative involved twenty artists, ages 40-75, to create a mural. The carefully conceived design allowed participants to experience a variety of therapeutic art techniques rich in tactile and auditory stimulation. When the mural was completed, many participants who were unaware of the retirement programs continued to visit the senior center.

Virtual Tour of Services DVD, Florida

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The Virtual Tour of Services DVD produced by ElderSource is breaking down barriers for elders and caregivers who have low literacy and difficulty understanding written brochures and techno-lingo. By providing a Virtual Tour of Services DVD—including senior center activities, in-home services, transportation, caregiver support and legal assistance—the agency increases the comfort level and understanding of its services for both staff and consumers. Funded by a $20,000 grant.

TECH (Teen Elder Computer Help), Oregon

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The Central Oregon Council on Aging (COCOA) developed and coordinates Teen Elder Computer Help, or TECH, an intergenerational training class that teams teenagers with seniors to teach Facebook, digital camera download, cell phone and Skype. The class helps seniors stay in contact with friends and family during a time when communication is transitioning to social networking. The program’s goal is to reach 100 seniors each year at five sites and give 30 high school students an opportunity to experience teaching.minimal administrative costs associated with coordinating volunteers and hosting a volunteer recognition event at the end of each session more than 150 seniors attended the classes and had 100 percent satisfaction and interest in taking more classes. The senior students also became advocates for the program through the local media, NPR and Wall Street Journal coverage the program received.

Mobile Resource Center, Florida

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ElderSource’s Mobile Resource Center (MaRCy) is an Internet-equipped “office on wheels” in a retrofitted RV complete with two computer workstations and outdoor furniture. Funded by the Community Foundation of Northeast Florida and National Council on Aging (NCOA), the RV allows ElderSource to bring its services to the people who need them most. According to ElderSource’s needs assessment, only 60% of elders in the area are aware of service/activities available to them and even those who are aware may not have a phone to call the helpline or the ability to visit in person. MaRCy allows staff to help elders find resources, obtain screening for services and apply for benefits at various outreach events throughout the agency’s planning and service areas. The branded vehicle is also a mobile billboard that builds awareness of ElderSource throughout the community. Initial cost was $61,000; Annual operating costs of approximately $50,000. 


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The program engages physicians, their office staff and community-based health and social service providers in a targeted training program to better coordinate health and social service programs for individuals with complex needs. Multiple providers who often rely on electronic communications learn to work together to coordinate care. By coordinating their communication, patient education and record-keeping methods, providers act as a multidisciplinary team without having to be co-located. Total program cost of $783,888 includes personnel.

Grandparents Raising Grandchildren, San Diego, CA

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Many of these older adults face challenges in navigating the complex maze of available health, education and social service programs. To help address this situation, AIS joined with community members to create the Grandparents Raising Grandchildren initiative, which provides education, support and resources for grandparents and kinship caregivers who are raising children; advocates for grandparents; and creates awareness about the unique needs of grandparents. Initial funding of $83,000 was provided through OAA Title III E National Family Caregiver Support Program funding and various community partners.

COVER to COVER: Connecting Older Veterans (Especially Rural) to Community or Veteran Resources, Utah

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Bear River Area Agency on Aging (AAA) led the development of Utah AAAs’ project, COVER to COVER: Connecting Older Veterans (Especially Rural) to Community or Veteran Resources, in which Utah AAAs partnered with the Veterans Health Administration (VHA) Office of Rural Health to train a staff member from each AAA to become experts in VA benefits. Now veterans and their families have a new access point in local communities to learn about and get connected to VA benefits and programs. Funded by the Veterans Health Administration (VHA) Office of Rural Health.

Good Health Good Living! eMagazine & Videos, Ventura, CA

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The eMagazine was posted on the agency’s existing website, and videos were posted for free on YouTube. Ventura County Area Agency on Aging (VCAAA) decided to create and distribute an eMagazine to celebrate the ways seniors are reinventing themselves and learning to use technology. Startup costs included purchase of video and camera equipment.

You Can, Live Well Virginia! Adapted Chronic Disease Self-Management for Elder Prisoners, Virginia

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Senior Connections has taken Stanford University’s renowned evidence-based Chronic Disease Self-Management Program (CDSMP) behind prison walls in the Greater Richmond region to address the needs of Virginia’s rapidly increasing aging population. This is the first time CDSMP has been implemented inside a prison, offering the opportunity for Virginia inmates to pursue a healthier lifestyle even while incarcerated. The program has positive effects for the 100 enrollees who have been diagnosed with chronic illness as well as for DOC, taxpayers, the medical system and Virginia communities receiving released inmates. Program expenses for programs at two prisons include salary ($22,000), travel ($1,000), equipment ($100) and participant supplies ($1,000). The program receives budgetary support from the Virginia Aging and Rehabilitation Services Department, small donations and grants, and in-kind contributions.

Healthier Living Alumni Online Community, San Francisco, CA

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The Chronic Disease Self-Management Program (CDSMP) is a six-week, evidence-based health education program developed by Stanford University to assist adults with ongoing health conditions. San Francisco Department of Aging & Adult Services (DAAS) worked with the National Council on Aging (NCOA) to provide an online community for CDSMP graduates, many of whom expressed interest in continuous support. Through the online community, graduates continue to have access to tools that support self-management, practice what they learned in the workshop, participate in forums, get support from others and share resources to better manage their chronic health conditions. They are also able to interact online with subject matter experts. at least 65 percent of CDSMP participants reported that the online community has helped them maintain or improve their mental and/or physical wellbeing, that they want to continue the service and that they believe the online community helps reduce their sense of isolation and has increased their community or social engagement. The experiences of the DAAS staff can be shared via Prezi, an online presentation, by request. Annual budget is $40,432. 

Choice & Independence via Technology, Michigan

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The program provides low-income seniors free basic computer classes and, upon completion, a free refurbished computer if they do not own one. Scholarships provide additional classes for those interested in personal enrichment or gaining marketable skills. Also, to expand the effectiveness and reach of the State Health Insurance Assistance Program (SHIP), RIV developed classes on navigating Medicare resources and benefit information online. inety-two percent report gaining increased marketable job skills, having reduced social isolation, and/or feeling empower to access health and wellness information via the internet. Low-income seniors received 115 refurbished computers, of which 97% still are in use. Through the Navigating and Welcome to Medicare classes, 155 Medicare beneficiaries learned to self-education, access benefit information and make plan choices for themselves. 180 seniors received 3,536 hours of free computer instruction (221 classes). Startup costs $22,000. Annual in-kind support from RIV includes staff time ($11,306) and volunteer time ($27,060).

ETAAAD Health and Independent Living Program, Tennessee

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Educational programming is recorded in a low-cost, high-definition recording studio set up in a local senior center. The 15- to 20-minute content is interspersed with 30- to 60-second public service announcements (PSAs). Professionals in a variety of fields lend their knowledge to programming focused on specific topics, supplying detailed information in a way that is accessible across the region. The final content is delivered to senior centers—where necessary equipment such as television and speakers have been purchased and installed—and is accessible to attendees at any time. Total capital costs of approximately $5,000 include two hi-definition cameras; Last fiscal year operating costs totaled approximately $1,300.

The Silver Key Coalition, Michigan

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The Silver Key Coalition (SKC) formed in 2013 to combat Michigan’s chronic in-home services (IHS) waitlist issues. The coalition brought together the statewide Aging Network, service providers and senior advocates to speak with a unified voice to make Michigan a “no-wait state” for senior in-home services so older adults can remain independent and in their own homes for as long as possible. The coalition is taking a data-driven, incremental approach in advocating for a $10 million increase in IHS funding by FY 2017. After one year of the campaign, the coalition is halfway to reaching that projected goal. Members have organized Meals on Wheels ride-alongs with legislators, provided testimony to and educated legislators on key issues, and presented each member with the signature silver key lapel pin. The coalition also produced a 38-page white paper documenting unmet needs and demonstrating the return on investment that would result from increasing state funding by another $5 million over the next two fiscal years.

Community and Health Services

Care Coordination | Fall Prevention

Putting a Fun Spin on Staying Healthy: 50 and Better Senior Health Fair, Des Moines, IA


More than 300 older adults attend each 50 & Better Senior Health Fair. Many, according to event evaluations, say they intend to change their health behaviors based on information received at the fair. By working with the older patients, the student volunteers gain experience and the time they served counts toward the "touch hours" required as part of their medical training. Attendees bring friends, enjoy the free refreshments, take ballroom-style dance lessons, play games and learn new things (chair yoga, for example). Among the free medical screenings are those for blood pressure, blood sugar, cholesterol and lipid levels, colorectal cancer, depression, skin cancer, vascular disease and vision. Other services range from foot exams, nutritional information and sleep assessments to bone density scans, medication reviews and osteopathic treatments.

Building a Community for a Lifetime, Auburn Hills, MI


Provides community center home to Meals on Wheels, congregate meals, fitness program that includes: volleyball, golf, tai chi, balance, yoga, walking activities, a diabetes-management program, a gym and a game room with a billiard table. Educational and social opportunities include professional storytelling, guest lectures, parties, arts and crafts classes, brain aerobics, language lessons, photography and computer training. Volunteers provide free estate planning and legal advice and can help older residents prepare their income tax returns. Community center participants don't even have to leave home for some services, including lawn mowing, yard maintenance and snow plowing. There's even a home-repair program. The center also offers transportation for dialysis, chemotherapy, shopping and other business or medical appointments. In addition, the center has a travel program that arranges trips to theaters, museums and casinos, as well as to such faraway places as Panama and China. Residents of Auburn Hills pay for the community center through their local taxes.

Gatekeeper Program, Multnomah County

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The Gatekeeper model has been applied nationally and internationally to train employees to identify and refer isolated, at-risk older adults residing in their own homes. These are elders who have little or no support system to act in their behalf as they experience serious difficulties that compromise their ability to live independently. Gatekeepers are nontraditional referral sources who come into contact with older adults or adults with disabilities through their everyday work or activities and who are trained:

Medication Reconciliation, Marin County, CA


Program includes intervention by a Public Health Nurse who visits IHSS clients and individuals aged 60 over in their home. The PHN conducts a thorough assessment of the individual’s prescription and over the counter medications. Using an individually tailored chart the PHN coaches the client to work with his/her physician and teaches correct medication management. The client experiences improvement in health, increased self‐ efficacy, reduction in IHSS medication assistance hours and reduced need for visits to the pharmacy.

Visual Medication Management Program, Georgia

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Many seniors take an overwhelming number of medications with unfamiliar names that are hard to spell and pronounce. The sensory disabilities and mental challenges many seniors face increase the likelihood that they will experience complications with their medications, including forgetting to take them. The lack of effective communication between seniors and their health care providers, pharmacists, family members and caregivers about their medications is also a serious concern. Properly managing medications is important to prevent complications, serious health problems and even death. The Visual Medication Guide (VMG) helps seniors manage their medications better by giving them a tool to associate each pill with its name. This pilot program collaborated with Northwest Georgia Public Health and IdentiMed LLC, which sold the VMG package to the program. two-year pilot program served 129 older adults in 13 senior centers and is positively received by seniors, family members and health care providers. The program is now an ongoing AAA service.

SOS (Senior Outreach to Services), Virginia

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Senior Outreach to Services (SOS) established a streamlined version of case management for the elderly to address gaps in care, incorporating an extensive outreach and follow-up component. The two-pronged approach reaches primarily low-income, isolated seniors through social workers who conduct one-on-one assessments, and through intervention and monthly onsite educational programs and screenings at income-based housing communities. SOS clients are typically over age 76 (many are over age 85), and about 90% have limited resources. SOS involves more than 150 public and private agencies, businesses, civic organizations, foundations and volunteers who partner on behalf of Peninsula seniors. The program, on average, links each client with three services. Budget for SOS is about $150,000.

Better Living at Home, Montgomery County, MD

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Better Living at Home is an innovative, cost-effective approach to serving older adults who desire to “age in place.” The program utilizes occupational therapists to conduct community-based assessments of older adults who are at risk of out-of-home placements due to functional impairments. The therapists collaborate with social work case managers and community health nurses in conducting a detailed assessment of the individual’s person-environmental fit and makes recommendations about how to maximize “fit” so that the individual (and family caregivers) can achieve maximum independence through their own resources and efforts. Where necessary and appropriate, Better Living at Home provides training and modifications, and procures and installs assistive technology to maximize independence. The occupational therapists typically conduct two to four follow-up visits after the initial assessment to determine if the environmental intervention is effective and if not, to modify it to meet the unique needs and circumstances of the individual. Costs less than $1,000 per client, including personal and operating expenditures. The major cost is staff, which is approximately 70 percent of total program expenditures. The remaining costs are for assistive technologies and installation. Preliminary results indicate that the program helped to reduce recommended hours of personal care service by 48 and to increase functional independence and safety (measured by the SAFER index) relative to the control group. In terms of cost-effectiveness, the program has generated an average program savings of over $7,000 for each $1,000 spent by the intervention.

King County Care Partners, Seattle, WA

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KCCP care management costs $299 per member per month for four RNs, two social workers, a clinical supervisor and medical director consultant, and project and data management, with an average of 300 active clients monthly. To improve quality and reduce costs, Seattle-King County Aging & Disability Services (ADS) partnered with Harborview Medical Center and four community health clinics to create the King County Care Partners (KCCP) multidisciplinary care management program. KCCP works with high-risk, Supplemental Security Income/Medicaid clients with co-occurring medical, mental health and substance abuse disorders. A multidisciplinary team led by skilled nurses and experienced social workers, work with clients in their homes and community-based clinics. The team coaches clients for up to one year in self-managing chronic disease, setting goals and learning how to effectively use the health system and available community resources, such as inpatient chemical dependency treatment centers. ADS provides the partnership with extensive experience in long-term care case management with a staff of social workers and registered nurses (RNs), project management and contracting, and knowledge of community resources. Early study results indicate that KCCP clients trust their care managers, are better able to get their health needs met and have reduced psychiatric inpatient costs, reduced criminal justice activity and better access to alcohol and drug treatment. In a 2009 client phone survey, 98% said they had a trusting relationship with their care manager, 92% said the health care goals they developed with their nurse covered their most important health needs, and 82% said KCCP helped them meet health needs they could not have met on their own. In a second study, relative to a comparison group, KCCP clients had lower psychiatric inpatients costs, fewer total arrests and charges, and higher odds of receiving inpatient alcohol and drug treatment.

Senior Whole Health (SWH), Massachusetts

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Senior Whole Health (SWH), a managed care program for older adults in Massachusetts, recognized that members with multiple chronic conditions could benefit from self-management programs to reduce readmissions and overall medical costs. SWH “bought it rather than built it” by partnering with the Elder Services of the Merrimack Valley’s Healthy Living Center of Excellence (HLCE), which has a centralized statewide infrastructure for program delivery. This statewide contract is the first of its kind. SWH reimburses HLCE for every participant who enrolls and completes an evidence-based program such as Chronic Disease Self-Management or Matter of Balance. WH program costs $50,000 per year, which includes implementation, management, materials, personnel and administration for 100 program participants.

HomeMeds Medication Reconciliation, Arkansas

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The HomeMeds computer software is designed so that case managers perform a medication inventory while in a client’s home and enter the information into the computer program. A computerized risk assessment screening and alert process identifies potential medication problems, which are sent to a contract pharmacist for further evaluation. Each one of these alerts represents improved health within this population of homebound older adults.  8:1 savings for this program. Annual costs include the HomeMeds Software license ($2,400) and personnel costs including care coordination, supervision and pharmacy consultation ($40,718). Start-up costs ($16,209.40) include planning consultation and webinars, wireless air cards, encryption software and implementation. Indirect costs are $7,224.98. Operating cost for the first year was $73,253.27.

Healthy Seniors at Home, Michigan

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The Healthy Seniors at Home project provides frail seniors who cannot attend site-based classes offered by RIV AAA access to chronic disease self-management training through an in-home information-sharing model. Volunteers for RIV AAA’s Senior Companion Program (SCP) who also have a chronic condition attend a six-week Personal Action Toward Health (PATH) class and then share what they have learned with homebound seniors through a peer-to-peer information-sharing model. Quarterly in-service trainings and ongoing staff support ensure volunteers maximize program impact. This variation on the evidence-based PATH program developed by Stanford University brings critical support to frail elders each week by teaching them chronic disease self-management skills, while also providing much-needed respite for their caregivers. Operating costs of $47,600 were funded through a three year commitment from United Way.

Community Health Navigator Program

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The Community Health Navigator (CHN) Program targets homebound individuals with multiple chronic conditions who are considered at high risk of hospitalization. The Agency initially developed the concept for this program to fulfill the need for a more cost-effective way to reduce hospitalizations. Community Health Navigators (CHNs)—including community volunteers, social work interns and retirees—use the Insignia Patient Activation Measure® (PAM®) software to develop behavioral action plans customized to patients’ ability and environment. CHNs work with participants to set goals and provide support to meet those goals during a six-month period. They call clients weekly and make monthly home visits—doing everything from organizing medications to helping create a list of questions for doctors. This is an innovative use of software that is normally utilized only in clinical settings. The program serves 250 homebound clients at a cost of $544 per person. Total annual costs of $136,056.

Exergamers Wellness Club, Los Angeles County, CA

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The City of Los Angeles Department of Aging (LADOA) formed a public/private partnership to develop and test a unique program to help older adults become better fit, reduce social isolation and track their health status over time. The Exergamers Wellness Club combines technology with evidence-based health promotion (EBHP) and education, exercise and personal health monitoring to improve health and well-being. This partnership, which includes Microsoft, highlights the transformative power of technology, specifically in its use of Microsoft Kinect for Xbox 360 to enrich exercise and Microsoft HealthVault to monitor personal health information in combination with LADOA’s EBHP and wellness programs. Microsoft paid development costs for the Exergamers Wellness Club, including Kinect, HealthVault programming/licensing and meters. The other partners provided the evidence-based health programs using combined resources including city general funds, Community Development Block Grants and Title III-D funding.

Institute on Compulsive Hoarding and Cluttering (ICHC), San Francisco, CA


The group is composed of major city departments: Department of Aging and Adult Services, Department of Building Inspection, Department of Public Health, housing providers and people with hoarding and cluttering problems. Through the relationships built in the taskforce, members work together across departments, to develop effective strategies to improve the lives of the consumers, improve health and safety conditions and prevent evictions. In 2009 the Taskforce published Beyond Overwhelmed, a comprehensive report on the impact of compulsive hoarding and cluttering and specific recommendation to reduce the negative impact. As a result of this community input DAAS issued an RFP for Social Support Services for Hoarders and Clutterers. MHA applied and has been funded since then.

Connections, Chico, CA


A comprehensive program that provides emotional, psychological, and social support for older adults, over the age of 50, who are experiencing emotional disturbances and serious mental illness. All services are conducted in the home and consist of a bio‐psycho‐social assessment, a client plan that may include counseling, case management, medication management support, and ongoing socialization support. Monthly monitoring is conducted to assess and address any individual need. Suicide prevention and education to both individuals and the community is also provided. Volunteers, Senior Companions assigned to clients, provide social connection and emotional support.

Intergenerational Work Study Program (IWSP), New York City, NY

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A collaboration between Department for the Aging and the City's Department of Education (DOE), IWSP provides high school youth with work experience delivering needed services to elders in senior centers, nursing homes, and home care settings.

Fitness Club Discount, New York City, NY

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NYC Parks offers older adults an affordable and extensive network of recreation facilities throughout the city. A senior membership is $25/year for anyone age 62 or over and allows access to 32 recreation centers across the city. Shapeup NYC, a program designed to encourage healthy lifestyles and improve the wellbeing of participants, offers free fitness classes at multiple locations across the five boroughs, including parks, community centers, and housing location.

The Best of Both Worlds: Care Manager in the Home & Nurse in their Pocket, Virginia

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The majority of the costs were absorbed by the CCTP. This resulted in net savings of $370,000, approximately $109 per patient per month. When Elder Services was charged with reducing hospital readmission within its six partner hospitals through the Community-based Care Transitions Program (CCTP) funded by Centers for Medicare & Medicaid Services (CMS), the agency discovered that although coaches who visit recently discharged patients in their homes helped reduce readmission, oversight by clinical nurses could further improve the program. To accomplish this, coaches who visit patients now use a special tablet equipped with Care at Hand (CAH) mobile technology, which provides coaches with questions tailored to the patient’s diagnosis, treatment and risk factors. If patient responses indicate a decline in health status, the system sends real-time alerts to a nurse coordinator, who helps the patient and coach address issues within 24 hours. With 561 patients for six months, total operating costs were $205,243.


Project Independence, Marin County, CA

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The program sends teams of public health nurses, social workers, program partners, community volunteers and nursing students to the homes of frail, isolated patients to support them in their recovery and transition from the hospital. The volunteers help patients manage medication, take them to appointments, shop and run errands, and provide information and referral. Compared to national data showing that about 23% of Medicare patients nationally re-enter hospitals within 30 days of discharge, the recidivism rate for participants in Project Independence is only 6%. Cost isless than $200,000 annually.

Interagency Care Team, Michigan

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Interagency Care Teams (ICTs) were formed to link people at high risk due to chronic health conditions and multiple hospitalizations with the help they need. The ICTs have flexible team leads and partners who are selected based on patient needs; use of a technology tool that allows multiple agencies to share progress notes; and AAA transition coaches and care management staff. This effort has led to reduced hospitalizations and increased patient access to community resources. Region IV AAA worked with fellow Healthy Berrien Consortium (HBC) partners to create a community roadmap of interventions and develop the ICT. Currently, health department epidemiologists are adding additional metrics for evaluation to extend the collaboration. Initial accomplishments for 130 patients include reduced hospital admissions, increased utilization of primary care providers and a reduction in total cost of care. Other important achievements include implementation of a communications tool, common patient education across agencies and increased access to community resources.

Eastern Virginia Care Transitions Partnership, Virginia

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EVCTP—comprised of five Area Agencies on Aging, five health systems and 69 skilled nursing facilities—combines medical and long-term home and community supports to reduce hospital readmissions and prolong quality life for patients living in their own homes. In addition to coaching, patients have access to enhanced services including transportation, home-delivered meals, in-home care and housing. EVCTP also helps created a seamless model of patient-centered care through enhanced agreements with hospitals for secure data sharing systems; trainings for governance, management and clinical teams; a single, centralized source for billing, tracking readmissions and other metrics; and integration into health systems’ electronic health records and health information exchanges. The Centers for Medicare & Medicaid Services (CMS) have recognized EVCTP as a “top performer,” with one of the largest and most successful CTI programs in the nation. In addition to reducing the readmission rate from 18.2% to 8.9%, the EVCTP program resulted in an estimated savings of $17,318,400 due to 1,804 avoided readmissions from February 2013 to January 2015. Currently, the readmission rate is 7%. For its startup year in 2013, total operating costs were $352,370; After enlarging the project’s footprint, the FY 2014 operating costs totaled $956,209.

Behavioral Health and Its Impact on Care Transitions, Massachusetts

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Trained Behavioral Health Coaches (BHCs) use evidence-based techniques—including Motivational Interviewing, Cognitive Behavioral Therapy and Stanford’s Chronic Disease Self-Management Education—to activate patients to take charge of and improve their health. BHCs assist high-risk patients immediately upon hospital admission, create an action plan and conduct weekly home visits for one month upon discharge, assist with accessing benefits and navigating the healthcare continuum, and then link patients to ongoing community services to decrease risk of readmission. The ability to replicate this program may depend on having a contract with CMS, Managed Care or an Accountable Care Organization.

Community Based Care Transitions of Southern and Western Wayne County, Michigan

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When The Senior Alliance was designated an emerging Aging and Disability Resource Center (ADRC) by the State of Michigan in 2010, the agency discovered few linkages and many misunderstandings between Area Agencies on Aging (AAAs) and hospitals. To remedy this challenge, the agency developed the Community Based Care Transitions Program of Southern and Western Wayne County, which builds on a foundation of the Care Transitions Intervention (CTI). Working with local hospitals enables the program to connect patients to more resources and provides new opportunities for collaboration. A coalition of more than 80 community agencies rely on a team approach to reduce patient readmission. The program bridges a variety of initiatives and interventions together, so a team (including hospital discharge nurses, social workers, community and hospital coaches, options counselors, etc.) works together to assist each patient. Through the program, local agencies also partner to provide discharged patients with round-trip transportation to follow-up visits and seven days of home-delivered meals. Centers for Medicare & Medicaid Services (CMS) funds this program. Costs fluctuate depending on the volume of referrals for transitions, transportation and meals, and geographic service area, mileage for home visits and other travel. Costs currently are estimated at $500,000 annually.

Atlanta Community Transitions Program, Atlanta, GA

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Inde Pendant Program, Michigan

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Through the Inde Pendant Program, more than 1,000 seniors waiting to receive in-home services were offered a Personal Emergency Response System (PERS) and fall prevention material free for one year. They also received a referral to a Home Injury Control (HIC) provider for help installing fall prevention devices. After a year, participants could pay $15 per month, about 30 percent below market rates, for the PERS. Eighty-three people agreed to participate in the program.  strategic effort to reduce wait lists by helping those seeking assistance use personal resources and alternatives to maintain independence safely and with dignity. Program participants experienced a 15 percent decrease in stress, anxiety and personal safety; 22 percent decrease in fall risk; 20 percent reduction in hospital admissions; and 20 percent reduction in emergency room visits at six months (increased visits at 12 months). In addition, 23 percent of those who received the PERS asked to be removed from the wait list for services, and 60 percent agreed to continue paying privately for the PERS after the 12-month pilot period. Costs include $7,500 for project manager and $15,000 in long-term care service dollars. The AAA 1-B is allocating between $15,000 and $20,000 annually to continue the program.

A Matter of Balance


8 session workshop to reduce fear of falling and increase activity among older adults. Benefits: 97% more comfortable talking about fear of falling; 99% participants plan to continue exercising; $938 savings in unplanned medical costs per Medicare beneficiary.

Falls Talk




The Otago Exercise Program


Individual program of muscle strengthening and balance exercises prescribed by a physical therapist for frail older adults living at home (80+). Benefits: 35% reduction in falls rate; $429 net benefit per participant; 127% ROI.

Stay Active and Independent for Life (SAIL)


Stepping On


7-week program that offers adults living in the community proven strategies to reduce falls and increase self-confidence. Benefits: 30% reduction in falls rate; $134 net benefit per participant; 64% ROI.

Tai Chi for Arthritis


Tai Ji Quan: Moving for Better Balance


Balance and gait training program of controlled movements for older adults and people with balance disorders. Benefits: 55% reduction in falls rate; $530 net benefit per participant; 509% ROI.

Legal Issues

Residents’ Rights, Your Right training program, San Bernadino, CA


As a part of the Red Cross Certified Nurses Aid (CNA) 126‐hour training, students are offered an overview of the history of the Ombudsman Program and long‐term care in the United States, as well as participation in exercises developed to heighten awareness of nursing home resident’s rights. Through these exercises, students are given an opportunity to learn the value of resident rights, while personalizing the effect of loss of ability, and status that the dependency of residing in a long‐term facility brings.

Marin County Financial Abuse Specialist Team (FAST), Marin County, CA


FAST is a collaboration between Marin County Division of Aging and Adult Services (DAAS) and the Elder Financial Protection Network (EFPN), a non‐profit. The Marin County FAST began in July 2010. This program, currently operating with nineteen volunteers, assists representative payee clients, partners with staff on financial abuse investigations and provides community education. This fiscal year alone, volunteers have logged in 946 hours to date.

Savvy Seniors, New York City, NY

City's Department of Consumer Affairs (DCA) has made 39 “Senior Savvy” presentations and tabling events reaching 6,629 seniors. DCA’s “Be A Savvy Senior” guide is available online. DFTA also has a Financial Savvy page, accessible through their Senior Savvy resource section. 59 initiatives.

Law Enforcement Card and Training Program, San Bernadino County

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The pocket-size, two-sided, accordion-style information card provides officers with penal codes applicable to elder and dependent adult abuse to assist them in filing proper charges against alleged perpetrators, while also outlining what APS can do in terms of treatment and services. DAAS APS social workers provide the informational card and training—which includes information on the signs and symptoms of elder/dependent adult abuse—directly to local law enforcement.

Legal Information for Elders (LIFE) Guide, Ventura County, CA

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Ventura County developed a Legal Information for Elders (LIFE) guide and a companion 2.5-hour class. The class is offered by the local Title IIIB legal service provider to county seniors age 60 and over, and covers a variety of common senior issues such as wills and trusts, probate, elder abuse, legal concerns when raising your grandchildren and solving disputes without using the court. The guide contains a resource section and detachable forms. Cost is $5,000 annually, which includes the salary of the attorney teaching the class and printing the guide. Elder Abuse funds were used to cover the costs.

MEAPA Intergenerational Project, Scottsdale, AZ

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Through MEAPA®, a volunteer alliance that promotes public awareness, education and community outreach for the prevention of elder abuse, the Intergenerational Committee developed a Generations Curriculum in which school-aged children partner with older adults to educate and mentor one another on topics such as respect, the aging process and role models. The Boys and Girls Club of Scottsdale helped create and pilot the eight-lesson curriculum, which features the message “Be Cool, Don’t Be Cruel.” The goal is to create a culture change where elder abuse is not acceptable from an early age.

Protective Money Management, Culpeper, Virginia

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Run entirely by trained volunteers, this Rappahannock Rapidan Community Services program helps low-income seniors and people with disabilities who are unable to manage their financial affairs. The program is unique in emphasizing full representative payee services, using online banking, Quicken and other technology to help serve rural residents; and in combining services to both older adults and those with mental disabilities. Critical information about the program is stored in a secure, web-based location and accessible even from a Blackberry. This use of technology allows the program to recruit very skilled volunteers who want to make the best use of their time and to link them with individuals in remote locations, as many transactions can be done online. The program provides a vehicle for social services agencies, law enforcement and family members to request help for clients and loved ones.

Skits to Prevent Fraud, Vermont

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The Senior Medicare Patrol (SMP) uses volunteer teams to provide statewide education, including resource information and assistance, to community members regarding health care, fraud, consumer issues and other mishaps. It was transformed from lecture format to a more-engaging theatrical format with skits and actors.

Faith to Fate: A Faith-Based Advance Care Planning Initiative for Underserved Communities, Virginia

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The Faith to Fate (F2F) Advance Care Planning Initiative seeks to assist with end-of-life medical and property-asset legal questions and provide free wills, advance medical directives and powers of attorney to members of African-American congregations and their surrounding communities within the Greater Richmond Virginia Metro region. F2F addresses the lack of advance medical and legal planning among older African-American adults through a partnership between Senior Connections, three institutional partners, several volunteer legal partners and six area churches. F2F involves a three-step sequenced process for each enrolled church: (1) a public announcement of the partnership, (2) a free, open educational forum conducted at the church by a Senior Connections staff member who is an Advance Care Planning Facilitator certified under Respecting Choices®, and (3) a half-day, by-appointment-only document-execution-and-delivery event sponsored at each church. To date, more than 2,000 congregants, plus their extended family members, have been educated. One hundred individuals have signed up or already received their executed legal documents.

Wills for Seniors, Jefferson Area, VA

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JABA hosts Wills for Seniors in conjunction with four teams of lawyers, law students and notary republics who volunteer their time to meet privately with seniors to prepare customized legal documents, including a will, a power of attorney and an advance medical directive. The event was created in 2010 when Andrew Nae, Jr., a local attorney, approached JABA with a partnership idea aimed at meeting the unmet need for legal assistance among low-income seniors. Wills for Seniors costs of about $200 include lunches, utilities and printing. All attorneys, notary republics and law students donate 100 percent of their time, so no additional financial support is needed. provided basic estate planning and legal services valued at $300,000 for more than 300 local, low-income seniors. JABA is willing to offer step-by-step training and hands-on assistance for any agency wishing to implement this easily replicable program. Materials on the process, schedule, documents used and more are ready and available for use by other agencies

Making Life Care Choices—Health Care Choices and Advance Planning, Merrimack Valley, Massachusetts

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Elder Services of the Merrimack Valley (ESMV) developed and implemented a training program for all agency staff to increase their understanding of Health Care Proxies (HCPs) and Advance Directives (ADs) and ensure they discuss key information about these documents with consumers. Session one uses the Conversation Project Starter Kit to provide general education on HCPs and ADs. The 5 Wishes booklets are utilized to explain the process of choosing an HCP and to help identify more personal end-of-life choices. Participating staff members complete the documents for themselves and discuss their process at the second session, which helps ensure they are familiar with the documents when they discuss them with consumers. Session two also addresses questions employees have about the documents and provides them with specific scripts and scenarios to assist them as they speak with consumers about their care choices. easily replicable because it uses the Conversation Starter Kit, which is available online and can be downloaded at no cost, and 5 Wishes, which meets the legal requirements for Advance Directives in 42 states, is available in 26 languages and can be completed online. Scripts and protocols relevant to the agency should be developed locally. Annual costs of $6,000 per year.

Healthy Aging: Advance Directives, New York City, NY

The City's Department of Health and Mental Hygiene (DOHMH) has developed an online resource for consumers seeking health care planning information. At this site, users can download forms with which they can designate health care proxies and also learn about related concepts, including living wills and do not resuscitate orders. Department for the Aging makes wallet-sized health care proxies available in English, Spanish, Russian, Chinese, Korean, and Bengali for distribution at appropriate educational and outreach events and 2 annual workshops. As an example of one creative partnership, in February, 2013, Peter Strauss from NYU Law School and law school students provided a 3-day workshop at Sirovich Senior Center on advanced directives. At the workshop, law students offered one-on-one sessions with seniors. Fifteen seniors signed up and received a one-on-one session, as well as a follow-up session in March. 59 initiatives .

Emergency Preparedness and Resilience

Disaster Kits for Homebound Seniors, Ventura, CA


Three‐day emergency supply kits delivered to homebound seniors throughout the county. Included in the kits are survival biscuits, a whistle, flashlight, water, emergency blanket, dust masks and a File of Life with a special insert of a personalized plan. Kits were hand delivered by MOW drivers and other social service workers and case managers. The File of Life contained in each kit had a special insert where seniors document their plans in the event of the need for them to evacuate their home. Additionally, each senior is given the opportunity to sign up for the County’s voluntary disaster registry. The disaster registry records a vulnerable senior’s location as well as any physical challenges such as blindness or mental disorders and special needs they might have such as oxygen, dialysis, etc. The information is then downloaded monthly into the Sheriff’s reverse 911 system and into the GIS Mapping program where the county’s emergency response personnel track vulnerable populations

911 Senior Emergency Cell Phone Program, Riverside, CA


The program is structured to protect and enhance the quality of life for at risk, vulnerable seniors 60 years of age or older and to provide them with emergency preparedness and security for fall prevention. Seniors or their live‐in caregiver are given a working condition cell phone to be used specifically for contacting the 911 Emergency Response Telephone Service. Cell phones are donated to Office on Aging by county employees and individuals from the community. The telephones are sent to a refurbishing plant for quality assurance testing and returned, ready for distribution. OoA was awarded a $5,000 one-time only SCAN Health Plan Community Grant.

Marin County Differential Response Program, Marin County, CA


In order to respond to the growing number of referrals to the Adult Protective Services (APS) program and in order to most effectively utilize staff expertise and to serve clients effectively, Marin County has developed a Differential Response Program as part of a best practice model. Referrals to the APS program are evaluated by supervisors and managers. If the primary presenting problem is medical self‐neglect, the case is evaluated out to APS and instead followed by a public health nurse or by a nursing student from a local nursing school.

Food Security

SNAP enrollment, New York City, NY

The Hunger Free Communities Grant was a two-year initiative (March 2011-March 2013) funded by the United States Department of Agriculture (USDA) for $2 million. The purpose of the grant was to provide education, outreach, and Supplemental Nutrition Assistance Program (SNAP) enrollment citywide. Department for the Aging (DFTA), the Council of Senior Centers and Services of New York City, Inc. (CSCS), and AARP specifically focused on an education and outreach program to inform seniors about SNAP and enroll those who are eligible at senior centers and other community based organizations. All sites and outreach events were located in neighborhoods with the highest proportion of under-enrollment of older adults in SNAP, according to research conducted by CSCS. Although the grant ended last March, because of the success of the program, AARP has agreed to continue funding the senior component of this grant in continued partnership with DFTA and CSCS. Since July 2011, 30 outreach sites have been established, 1,400 older adults have been screened for SNAP benefits, and 650 older adults are receiving SNAP benefits. Each enrolled individual receives an average monthly SNAP benefit of $147. Additionally, the City's Human Resources Administration (HRA) does SNAP outreach to about 50 to 60 senior center sites annually. 59 initiatives.

Home-Delivery Meal Enrollment - RedesignNew York City, NY

Department for the Aging (DFTA) engaged in a redesign of the City's case management and home-delivered meals programs in order to increase efficiency. Two particularly successful examples of improvements to the two programs through the redesign are the Home Delivered Meal (HDML) Pilot, where several HDML programs were given the go-ahead to directly enroll meal recipients rather than relying solely on the case management agency, and the Case Management Agency (CMA) Targeted Initiative, where CMAs with particularly high demand were awarded additional staff to bring on board more meal recipients. Taken together, the two initiatives reversed several years of chronic under-enrollment, so that virtually all program capacity for home delivered meals is now being utilized. 59 initiatives.

Choice, Missouri


The Mid-East Area Agency on Aging (MEAAA) worked with a local café and Panera Bread, a national restaurant chain, as catered meal providers. Using a custom website developed by MEAAA, participants can register in advance to attend upcoming programs and select their meal from a menu of healthy options. A total of 3,189 meals have been served, with an average contribution three times what is collected at senior centers. Surveys reveal that as a result of Choice, 81 percent of participants are more aware of community resources, 43 percent have used new resources, 65 percent are “living a healthier life” and 50 percent are socializing more.

CHAMPSS: Choosing Healthy and Appetizing Meal Plan Solutions for Seniors, San Francisco, CA

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To attract younger seniors to meal programs and address the lack of affordable space for congregate meal sites, San Francisco Department of Aging and Adults Services (DAAS) created Choosing Healthy and Appetizing Meal Plan Solutions for Seniors (CHAMPSS). The congregate meal program model attracts younger seniors by providing meals in a restaurant and offering flexible dining times and a menu of meal options. DAAS worked with Self-Help for the Elderly to pilot CHAMPSS with a local restaurant interested in serving seniors. This approach eliminates the stigma of eating at a senior center and provides greater access to meal services at times that work for seniors. After enrolling in the program, seniors are issued a CHAMPSS card that staff at the restaurant can swipe to record the meal served and debit the donation. Because they are dining at a restaurant, seniors often invite friends or family to join them, which increases social connection and reduces isolation. DAAS cost for CHAMPSS is about $8 per meal, including tax and tip, which is about $1.50 higher than traditional congregate meal program costs. CHAMPSS currently operates at two sites that serve an average of about 200 meals per day. To date, 3,500 seniors are enrolled—an increase of more than 170 percent in the second year. Participant demographics show that the program successfully attracts younger seniors, many of whom are participating for the first time. DAAS is willing to share experiences and resources including information on the software vendor used, the template for the restaurant agreement and checklists used by CHAMPSS restaurants. The key to success is finding a restaurant that is accessible and welcoming to seniors.

SNAP-Ed for Seniors Community Engagement Program, San Diego, CA


County of San Diego, Aging & Independence Services (AIS) combined direct nutrition education with its own policy, system and environment (PSE) intervention. The 14-session curriculum is designed to help seniors identify barriers to accessing healthy food or physical activity and select a project aimed at reducing those barriers. U.S. Department of Agriculture–funded SNAP program. This component cost approximately $60,000 to conduct with four cohorts.

Heritage Pet Assistance Program, Iowa


The Heritage ‘Tails-a-Waggin’ Pet Assistance Program helps older adults care for their companion pets. Because of limited income or a lack of transportation to get to a store, some frail seniors feed their home-delivered meals to their pets, creating nutrition problems for themselves. With the help of local agencies and Heritage’s nutrition providers, volunteers and other community workers, this program provides seniors with pet food and care products each month, enabling them to properly care for and keep their animals with them at home. In addition to pet food, products include cat litter, litter boxes and puppy-training pads, which help seniors maintain a safer and more sanitary home environment.

Simply Delivered to ME, Maine


Many older patients leave the hospital malnourished, which can increase the risk of readmission. Simply Delivered to ME was created to test the effect of home-delivered meals on the 30-day rate of readmission at Maine Medical Center (MMC). Upon hospital discharge, participants in the Southern Maine Agency on Aging Community-Based Care Transitions Program (CCTP) and their caregivers were eligible to receive seven meals. The frozen meals were delivered to patients’ homes within a few days of discharge, and all recipients received a follow-up call near the end of the week to determine if the meals were helpful and to offer the home-delivered meals program to eligible patients. The readmission rate was 10.4%. $120,000 in private funds from foundations and a physician health organization supported the project for two and a half years.

We Sustain Maine, Maine

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Spectrum Generations, Central Maine’s Area Agency on Aging, created WSM in fall 2011 to provide higher quality, more nutritious meals for seniors by including locally grown food in its six county senior nutrition program. Providing healthy, nutritious local food year-round involved remodeling two Community Center kitchens and buying two “flash” freezers. These upgrades allow the agency to bulk purchase Maine food products during peak season and properly store them for later use. The nearly $300,000 raised through donations and grants from individuals, organizations and foundations funded food ($25,000) and the onetime cost to install new freezers and renovate two kitchens ($264,700).

Dining with Dignity

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ElderSource developed a toolkit of assistive eating devices to help older adults with health conditions such as arthritis, paralysis and Parkinson’s disease, eat with dignity and improve their nutrition and quality of life. The toolkit includes sample devices, such as specially designed eating utensils and cuffs, lipped and non-skid plates, customized cups; and devices to help turn knobs and lids, and grab items from shelves. Also included in the kit is a guide that describes each device and how to use it. Case managers explain the devices to clients, take their orders through the agency and deliver the devices to the consumers. These devices help restore dignity, confidence and independence to seniors who otherwise might refrain from eating because of physical limitations caused by pain, tremors or paralysis, which can cause spills, dribbling and other problems preparing and eating food. These devices also help alleviate malnutrition among elders and support caregivers in their duties by saving them time and enabling them to complete other tasks. The kit cost is $283, plus $40 for a duffle bag to transport it. The program purchased nine kits and had an additional $7,267 to buy the actual devices.

Local Food Partners for Enhanced Senior Nutrition, Vermont

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This project facilitates the purchase, delivery and use of fresh, locally grown food by senior meal programs in Northeastern Vermont. Working with several other community organizations, the Area Agency on Aging for Northeastern Vermont (NEVAAA) created a regional food distribution system in 2009 to support the health and well-being of older Vermonters by offering senior nutrition providers easier access to locally grown food. A partnering organization, Green Mountain Farm Direct (GMFD), creates a biweekly “order sheet” listing products of more than 20 local farmers and producers, and distributes it via email and fax to senior meal programs participating in the program. Kitchen staffs place their food orders by phone or fax to GMFD, which consolidates the order and coordinates delivery. Educational materials and hands-on workshops provide support and training to meal providers on planning menus and preparing fresh food. Workshop topics include visits to local farms, seasonal menu planning and opportunities for regional meal program staff to work together to create meals and share knowledge.

Elderly Nutrition Food Box Program, Iowa

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The Elderly Nutrition Food Box addresses the need of elders on a fixed income who struggle to choose between food and medications or other bills each month. The program targets those at risk of malnutrition and ho may have transportation difficulties. Each month all Hawkeye Valley older adults in the home-delivered meals program received a fifteen-meal food box. The food bank orders the food and arranges for volunteers to pack the boxes. The food bank delivers the meal boxes to senior centers who in turn find volunteers to distribute them to the home-delivered meal participants. In January 2008, Hawkeye Valley AAA began offering a two-meal weekend bag to congregate meal participants to use when meals are not provided. The meals boxes include non-perishable foods, baked goods and fresh produce when available, and address food insecurity and additional health problems among older adults. Because boxes are delivered in the late afternoon, Hawkeye Valley AAA has been able to tap into a whole new group of volunteers to deliver them—including youth church groups, Boy Scouts, Girl Scouts, 4-H members, parents and their children, service organizations, and home-delivered meal volunteers.

Senior Nutrition Program Placemats, Ventura, CA


Ventura County Area Agency on Aging (VCAAA) created Senior Nutrition Program placemats as an educational tool to boost awareness of healthy and affordable food options for low-income older adults. The placemats, which are available in English and Spanish and change monthly, aid seniors at congregate meal sites or who receive home-delivered meals by educating them on affordable, healthy food options. The placemats feature a recipe approved by VCAAA’s registered dietitian using ingredients purchased at the “99 Cent Store.” Additionally, the placemats showcase YOUR PLATE, which displays the percentage of fruits, grains, vegetables and protein that a senior should consume per meal. The back includes the phone number of a registered dietitian seniors can contact with questions or to set up one-on-one nutritional counseling, as well as tips related to optimal aging, exercise, healthy living, senior scams and community resources. VCAAA has experienced a 300 percent increase in seniors wanting one-on-one nutrition counseling, a 10 percent increase in congregate meals provided and a 50 percent increase in requests for nutritional education sessions. Because of increased demand, VCAAA is now offering two unique placemats each month.

Meal Runner Program

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The Meal Runner Program recruits students to help senior volunteers deliver meals to the homes of the elderly. The program began in 2006 when the Mid-East Area Agency on Aging (MEAAA) collaborated with a local high school to recruit students as meal runners for the South County Senior Center’s Home-Delivered Meal Program. The senior center has 14 volunteers, 13 of whom are seniors themselves (with an average age of 78). Delivering up to 16 meals per route in varying weather conditions proved taxing to volunteers, who have to load heavy meal carriers and coolers, get in and out of the car numerous times, and unload and carry meals into a number of homes and apartments that required a lot of walking and step climbing. The Meal Runner Program alleviates most of the physical strain and effort on senior volunteers. Student volunteers do the lifting, loading and meal delivery at each stop, while the senior volunteers focus on their routes and driving safely to each destination. no expenses related to this program


Building Better Caregivers TM


6-week workshop for family caregivers. Developed at Stanford University, the program has been recognized for its ability to reduce caregiver stress and depression, and increase their overall well-being. Department of Veterans Affairs’ Caregiver Support Program, Canary Health, and NCOA make this program available to veterans through an innovative partnership to provide self-management support for family caregivers.

Caring for the Caregiver, Westchester County, NY


provides professional training to volunteers who then mentor family caregivers. "caregiver coaches" play an "enhanced good neighbor role" by helping often-overwhelmed family caregivers understand their options and make informed decisions about caring for an older or disabled loved one in their own or their relative's home. The coaches become a stabilizing force and sounding board. a phone-based program, The volunteers learn coaching techniques and receive the Resource Guide containing local and national contacts for aging and caregiver assistance. After training participants attend monthly Caregiver Coach Conversations to discuss specific issues, their experiences, ideas and concerns. Coaches make a one-year commitment to the program, providing invaluable support to caregivers, often via telephone. The amount of time each coach devotes to a family caregiver varies depending of the needs and situation. Livable Communities Caregivers Coaching Program The program offers classes quarterly and average 12 to 15 people

Family Caregiver Support Program Outreach Campaign, Los Angeles, CA


For this campaign, AAA produced and distributed brochures, posters and bookmarks to get the word out county‐wide. The goal was to inform as many county residents as possible on the services available for unpaid family and grandparent caregivers. In addition, the Information and Assistance Van displayed the Caregiver logo so that information can be disseminated at fairs and outreach events county wide

Caregiver Coalition Lunch & Learn Webinars, San Diego, CA


Lunch & Learn webinars provide easy access for working family caregivers to attend professional workshops targeting their needs in providing care for loved ones. The online workshops are digest versions of traditional “Finding the Balance in Caregiving” conferences produced by the local Caregiver Coalition. Each webinar is approximately one‐half hour during the Friday lunch hour, featuring attorneys, doctors, social workers, and other professionals. The webinars are interactive and allow questions. Recorded sessions enable caregivers to watch them “on demand.” The webinars are a convenient and cost-effective way to make the same information available to caregivers that they would get at traditional conferences. 267 caregivers took advantage of the 18 webinars offered in 2011. More than 90% of 84 participants who completed evaluations assigned the webinars a four or five rating on a scale of one to five – with five being the best – for the overall experience. About 67% of respondents gave the highest satisfaction to the information presented, with 95% of these respondents assigning a rating of four or five. If existing online webinar software is not available, the cost of buying a webinar software license is about $4,000 annually, depending on capacity.

Caregiver Training Coalition, Santa Cruz, CA


Local agencies, including the AAA, the Caregiver Resource Center, the Adult Day Health Care Center, Lifespan & Visiting Angels (for‐profit home care agencies), Hospice, Meals on Wheels, the County of Santa Cruz & Cabrillo College collaborated to put together a series of 8 classes for entry‐level caregivers and/or family members, providing essential skills to the new caregiver and an introduction to the field for those seeking a career. Completion of the series earns the student a Caregiver Training Certificate of Completion. The program is now self‐sustaining, using regular Extension class fees to cover instructor costs and support a part‐time coordinator.

Volunteer Caregiver Respite Program, Ohio

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The Volunteer Caregiver Respite Program helps family members caring for frail, aging loved ones alleviate stress by providing them a temporary break. Each week, a Retired Senior Volunteer Program member visits with the aging loved one at home for two to four hours so the caregiver has some time off. The new relationships formed benefit the volunteer and care recipient at the same time that the caregiver gets a much-needed break. The Volunteer Caregiver Respite Program merges two existing programs—the National Family Caregiver Support Program (NFCSP) and the Retired Senior Volunteer Program (RSVP)—to provide evidence-based training through Respite Education and Support Tools (REST) and coordination for caregivers. Training for volunteers is subsidized by grant funding.

Caregiving MetroWest, Boston

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After MetroWest Health Foundation identified the need for a single online access point for caregiving information, it provided planning and implementation grants to support BayPath’s efforts to make the site a reality. provides family caregivers in 25 MetroWest Boston communities real-time information and interaction, including a clickable map that allows users to view location-specific resource listings, an interactive glossary of caregiving terms, a blog, an assessment tool and a “Wellness Wall” offering tips and advice. web portal’s first two years, 23,573 unique users have registered 86,214 page views. BayPath is willing to provide technical assistance. Funded by $325,000 in grants.

High Country Caregiver Foundation, North Carolina

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In response to caregivers’ growing needs for services and supports in northwest North Carolina, the High Country Area Agency on Aging’s Family Caregiver Support Specialist (FCSS) created the High Country Caregiver Foundation (HCCF). The program started small with a fundraiser to cover nonprofit status application costs, but has since expanded to net more than $121,000 from a variety of monetary and in-kind resources to help meet the caregiving needs of a seven-county region. One component is the respite voucher program, which allows caregivers to use vouchers for negotiated rates at home care agencies and adult day care, independent living and assisted living facilities. The Relatives as Parents Program (RAPP) provides services and supports based on the needs of individual families, while also offering group services such as support meetings and school supply and holiday gift drives.

Livable Communities Care Circles of Westchester Program

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Westchester County has an estimated 33,000 caregivers caring for loved ones age 60 and older. Many family caregivers, often overwhelmed by their responsibilities, do not know where to find the help they need. In 2011, the Westchester County Department of Senior Programs and Services (DSPS) Caregiver Collaborative developed the Livable Communities Care Circles of Westchester Program to help caregivers effectively manage daily responsibilities. The program trains caregivers how to seek assistance from volunteers by creating Care Circles of individuals who help them accomplish such daily tasks as preparing meals, walking the dog or simply providing companionship. Caregivers receive the “Step Forward and Give Back” guide—a step-by-step manual on how to start and maintain a Care Circle. The guide also provides practical information on caregiver issues in general and on community resources that caregivers may find helpful. The goal is to empower caregivers to step forward to access the help of a volunteer who gives back as a part of their Care Circle. The “Step Forward and Give Back” guide addresses general caregiver issues and would require few alterations to customize with resources that reflect the community being served.

Rural Community-Based Caregiver Network and Support, Maine

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In 2009, Eastern Area Agency on Aging and a group of already collaborating organizations formed the Rural Community-Based Caregiver Network and Support to expand services and support options for rural caregivers. Their unique solutions to Maine’s rural caregiver challenges include scholarships to fund services, mini-grant contests to offer new services and internships to inspire career choices in geriatric fields. Three-year expenses totaled $1.3 million.