Center For Hope SI (CFHSI) is proud to introduce the Community Care Connections (CCC) program, a visionary initiative designed to seamlessly blend community-based aging services with healthcare. This comprehensive evidence-based approach aims to address the critical gaps identified within the aging population’s care continuum while working with all older adults we specifically target low-income, marginalized older adults to reduce Health equities in Staten Island.
At the heart of our initiative is the implementation of the highly regarded “4Ms” care model, which emphasizes what Matters most to older adults, Medication, Mentation, and Mobility. The 4Ms are essential components of high-quality care for older adults and, when implemented together, result in significant improvements. We will utilize the 4M model as the framework to assess Health-Related Social Needs (HRSN). This person-centered approach aligns perfectly with our goal of enabling older adults to age gracefully and healthily in their preferred settings, surrounded by their social support networks. By focusing on these key areas, we strive to tackle the social determinants of health (SDOH) head-on, ensuring a higher quality of life for our program participants.
Phase 1:
In our commitment to offering accessible and inclusive services, we have forged strategic partnerships with adult Community Centers, Friendship Clubs, Adult Day Care Centers, and other CBOs. These partners act as referral sources for individuals who have had at least 2 or more emergency room visits within the last 12 months and have both Medicaid and Medicare that could greatly benefit from our comprehensive support and services.
Phase 2:
Expanding our reach, the second phase involves collaboration with hospitals and other healthcare facilities. Upon discharge, patients assessed at risk for avoidable rehospitalizations and have had at least 2 or more emergency room visits within the last 12 months and have both Medicaid and Medicare are referred to our program for in-depth case management, significantly reducing the likelihood of readmission.
This program represents a vital step towards enhancing healthcare for Staten Island’s older adults. By bridging gaps in care, promoting collaboration, and emphasizing individual needs, we’re fostering healthier, more connected, and fulfilling aging experiences for our community’s older adults.
To find out more about our program.
