Hebrew Rehabilitation Center - 2022 Community Health Needs Assessment and Implementation Planning

2022 Community Health

Needs Assessment and

Implementation Plan

Hebrew Rehabilitation Center

1200 Centre Street

Boston, MA 02131

Published September 7, 2022

Includes Spanish language version of 2022 Implementation Plan

Executive Summary

Hebrew Rehabilitation Center, a teaching affiliate of Harvard Medical School and part of Hebrew

SeniorLife, is a licensed long-term chronic care hospital that offers geriatric specialty care that

meets the chronic and acute medical needs of older adult patients in a therapeutic and healing

environment. Founded with the promise to honor our elders, for almost 120 years we have

served seniors’ health care needs in several communities within the city of Boston, and in the

towns of Brookline, Chestnut Hill, Dedham, Needham, Newton, Wellesley, Weston, and

Westwood.

As the flagship health care provider of Hebrew SeniorLife, a Harvard Medical School affiliate

and nationally known senior services leader that provides communities and health care for

seniors, research into aging, and education for geriatric care providers, HRC is a leader in

advancing health care for seniors and delivering high quality, evidence-based senior care and

wellness.

At HRC, it is our priority to keep seniors healthy and safe in their homes, until a choice is made

that a more advanced level of care may provide a better life. Through our array of services to

our community outreach efforts, we educate seniors and their families on the necessary steps

and care needed to remain independent.

We know first-hand the health challenges of older populations. In Massachusetts 17 percent of

the population is 65 years old or older. Life expectancy is 80.4 years, sixth-highest in the United

States, almost a full two years higher than the overall life expectancy in the U.S. Source:

https://www.seniorliving.org/massachusetts/

This 2022 Community Health Needs Assessment provides a comprehensive review of unmet

health needs of the HRC community, including the negative health impacts of social and

environmental conditions. The CHNA Committee analyzed community input and available public

health data, and conducted an inventory of existing programs. While the COVID-19 pandemic

that started in 2020 and continues through today impacted the timing and delivery of certain

programs, we did make solid progress against our goals. Key learnings, and research from

these efforts, factor prominently in the development of the 2022 CHNA and implementation plan.

We also considered these focus areas as identified in 2017 by the Executive Office of Health

and Human Services (EOHHS) and the Department of Public Health (DPH) including:

● Chronic Disease with a Focus on Cancer, Heart Disease, and Diabetes

● Housing Stability/Homelessness

● Mental Illness and Mental Health

HRC agrees with the Attorney General’s “Building Toward Racial Justice and Equity in Health: A

Call to Action,” that describes the health care system’s failure to equitably serve the

Commonwealth’s most vulnerable residents. We take seriously the urgency to address health

inequities caused by racism and institutional bias and their influence on the social determinants

of health and also as an independent factor affecting health. We demonstrate our commitment

to make an impact on these disparities through accessibility and specific services detailed in our

2022 CHNA and implementation plan.

Our CHNA findings show that seniors in our communities need assistance with the following:

● Geriatric Specialists and Services

● Behavioral/Mental Health Health

● In-Home Health

● Social Determinants of Health

In response to these findings, HRC developed the included 2022 Implementation Plan which

documents target population, programmatic objectives, activities/strategies, partners, and

metrics.

We thank members of the HRC community for their helpful guidance and input in compiling this

2022 CHNA. We look forward to your joining us on this journey to redefine the experience of

aging and our mission to deliver health care in new ways to meet the needs of today’s seniors

and those to come.

We invite you to become involved by exploring ways to volunteer at HRC – on your own

schedule, days, evenings, and weekends. No matter how much time you have to give, you will

make a difference! Through our robust volunteer program, you will receive on-the-job training

and supervision, and an opportunity to belong to a wonderful group of caring people.

Table of Contents

Table of Contents 4

Introduction to Hebrew Rehabilitation Center 5

Background/Overview 5

Purpose 7

Service Area 7

Patient Population Demographics 8

Services Offered 9

Impact of COVID-19 14

Summary of Approach and Methods 16

Community Engagement Process 16

Quantitative Data Collection 17

Community Resources 18

Approval 19

Key Findings 20

State Population Trends 20

Community Survey Trends 21

Language 21

Food Access 22

Access to Care and Transportation 23

Brain Health/Dementia 23

Community Health Priorities Implementation Plan 25

2019 Summary 25

Defining HRC Priorities 25

Appendices 27

Appendix A: 2022 Community Health Survey 27

Appendix B: CHNA Management Structure 32

Appendix C: Health Care Services Committee 33

Appendix D: 2019 Community Health Needs Assessment Implementation Plan Results 34

Appendix E: 2022 Community Health Needs Assessment Implementation Plan (English language version) 42

Appendix F: 2022 Community Health Needs Assessment Implementation Plan (Spanish language version) 48

Introduction to Hebrew Rehabilitation Center

Background/Overview

At HRC, our continuum of health care services reflects best practices informed by the latest

geriatric research, including studies from our own Hinda and Arthur Marcus Institute for Aging

Research. Our approach to care is personalized according to the goals of the seniors we serve

and their families with a focus on maximizing independence, quality of life, and dignity by

helping each patient optimize their activities of daily living and functional mobility.

HRC’s inpatient services, which include long-term chronic care and post-acute rehabilitative

care, reflect the best options possible to meet any given individual's goals for care. We strive to

create the best living environments for patients, promote wellness, and establish caring

practices that provide a personal, nurturing touch. Our staff members deliver medical and

psychosocial care that encourages involvement from patients and families in the

decision-making process. We are proud of again earning in 2021 the Five-Star rating from the

Centers for Medicare & Medicaid Services, created to help consumers compare facilities more

easily. HRC proudly received additional numerous quality performances and achievements in

2021 and early 2022:

● HRC-Boston in Roslindale and HRC-NewBridge in Dedham Recuperative Services Units

named in 2021-2022 U.S. News Names Best Nursing Homes

● HRC-Boston and HRC-NewBridge named by Institute for Health Improvement as an

Age-Friendly Health System

● The Boston Globe/The Commonwealth Institute 2021 Top 100 Women-Led Businesses

● The Boston Globe Top Places to Work 2021 Massachusetts

● 2021 Top 25 Hospice Consumer Assessment of Healthcare Providers and Systems

(CAHPS)

Medical care is provided by clinicians from our Department of Medicine, which is one of the

largest geriatric practices in Massachusetts. Many of our physicians are affiliated with Harvard

Medical School, and the practice includes geriatricians, geriatric nurse practitioners, geriatric

psychiatrists, and other specialists. In addition, our integrated care team of nurses, therapists,

social workers, and chaplains provides inpatient post-acute and long-term chronic care, and to

seniors in the community—also adult day health care, outpatient specialty care, and geriatric

primary care. Our care team also teaches students, professionals, and families who seek

geriatric expertise, conducts research in health care services and clinical geriatrics, and serves

as advocates for older patients.

Our Partners

The oft-heard phrase, “It takes a village,” extends to the care and wellness of our seniors. At

HRC, our physicians, other clinicians, and staff advance the standard of health care for seniors

through innovative and specialized geriatrics expertise. We are proud of our relationships with a

number of preferred provider partners that lead to improved health and quality of life for seniors.

Together we are creating opportunities to provide the highest standards of clinical care for our

mutual patients. Extending beyond our affiliation with Harvard Medical School and into the

community, we are preferred providers for the Beth Israel Deaconess Medical Center and the

New England Baptist Hospital, now part of Beth Israel Lahey Health. These reciprocal

relationships ensure that patients within our care have access to top quality acute- and

specialty care facilities should they be needed.

Hebrew Rehabilitation Center Geography: Licensure

HRC operates under a long-term chronic care hospital license with 675 beds in the following

three locations.

Boston: HRC-Boston, located at 1200 Centre Street in Roslindale, a neighborhood of the city of

Boston, is licensed for 405 long-term chronic care (LTCC) and 50 long-term acute care (LTAC)

beds. Outpatient services are also provided under this license.

● The 50 Skilled Nursing Facility (SNF or short-term rehab/RSU) beds at HRC-Boston are

operated by HRC under a SNF license from the Department of Public Health/Medicare.

● Adult Day Health is operated by HRC with a separate license from MassHealth.

● HRC outpatient services are provided in outpatient clinical settings in Dedham and

Roslindale, offering a range of outpatient programs that provide specialized care to

seniors in the Greater Boston area. From primary care to rehabilitative services to

memory care to wellness programs, our outpatient services help seniors stay healthy

and independent, and enjoy the best quality of life possible.

Dedham: HRC-NewBridge, 7000 Great Meadow Road, Dedham, has 220 of HRC’s long-term

chronic care (LTCC) licensed beds. Outpatient services are also provided at this HRC location.

● The 48 Skilled Nursing Facility (SNF or short-term rehab/RSU) beds at HRC-NewBridge

are operated by HRC under a SNF license from the Department of Public

Health/Medicare.

The local communities served, as defined by our licensure, are Boston and Dedham.

Purpose

Why a Community Health Needs Assessment?

This assessment is aligned with the federal Patient Protection and Affordable Care Act (PPACA)

that calls for private, nonprofit hospitals to conduct community health needs assessments once

every three years and to develop implementation strategies to meet the community health

needs identified through the process. We evaluated community health needs in 2013, 2016, and

2019 prior to this 2022 update. This tri-annual, disciplined approach demonstrates HRC’s

commitment to addressing the needs of the seniors in our community and helping them manage

and maintain their health at every stage of their lives.

Service Area

Zip Code of Origin Analysis

The community served

by HRC consists of

thriving Boston

neighborhoods and

bustling suburbs in the

Greater Boston area.

Based on our analysis of

the market and the

communities we serve,

the black circle in the

map on the left illustrates

HRC’s primary service

area.

Based on patient zip

code of origin, the HRC

core service area is

within an approximate

five-mile radius from our

campuses in Roslindale

and Dedham, as the

crow flies.

Based on patient zip code of origin, the local communities we serve are particular

neighborhoods of Boston and the towns of Brookline, Chestnut Hill, Dedham, Needham,

Newton, Wellesley, Weston, and Westwood.

Community

Zip Codes

Community

Zip Codes

Allston

02134, 02134-5015

Needham

02492, 02944

Brighton

02135

Newton

02458, 02459, 02460, 02461

Brookline

02445, 02446

Roslindale

02131

Chestnut Hill

02467

Roxbury

02118, 02119, 02120

Dedham

02026

Wellesley

02481, 02482

Dorchester

02122, 02125

Weston

02493

Jamaica Plain

02130,

Westwood

02090

Hyde Park

02136

West Roxbury

02132

Patient Population Demographics

Age/Gender

In addition to licensure and zip code of origin, the CHNA committee reviewed current hospital

and community demographic and environmental data.

Current Hospital Patients

HRC provides services to seniors. Approximately 90 percent of the patients of HRC are older

than 65. Those younger include many employees receiving outpatient and therapeutic services.

Age at Admission - 2022

Campus - Service Line

Median Age

Average Age

HRC Boston - LTCC

HRC - Memory Care

HRC Boston- SNF

HRC Dedham - LTCC

HRC Dedham - SNF

Adult Day Health Brighton

Insurance Profile

Approximately 80 percent of the patients in our long-term chronic care are dual eligible for

Medicare and Medicaid coverage. The remainder of our long-term chronic care population is

private pay, with Medicare and other insurance providing auxiliary service coverage.

Massachusetts has an “individual health insurance mandate,” which requires most adults to

carry health insurance if it is affordable to them and that meets certain coverage

standards (referred to as “Minimum Creditable Coverage”).

Services Offered

The 2016-2022 Hebrew SeniorLife Strategic Plan set the direction for HSL to do an even better

job of fulfilling our strategic aim, which is to improve the quality of life for a growing number of

seniors and their families, with a focus on the most vulnerable and under-served seniors. The

Strategic Plan comprised five strategic approaches, one of which is directly relevant to our

CHNA Implementation plan: We plan to proactively reach more seniors in the community

and engage them earlier.

In 2017 we embarked on a business planning effort that resulted in HSL’s 2019-2023 Business

Plan, developed to establish a comprehensive and consistent organization-wide service line

model and financial plan to support our 2016-2022 strategic plan, and that also reaffirmed our

commitment to reach more seniors in the community and engage them earlier.

We recognize that seniors have evolving expectations and expect more, and different, services.

They want to age in place, prevent and manage chronic disease, and maintain their active

lifestyle as long as their health permits. Because they are living longer, their medical needs will

be complex, and many will require long-term supports and services. As such, seniors who live in

their own homes require services that span education and prevention, direct care, and other

forms of assistance. Since publishing our 2019 CHNA, HRC is increasingly focused on the

needs of seniors who live at home in the communities we serve.

From HRC’s outpatient wellness cluster in Roslindale, to the outpatient Deanna and Sidney

Wolk Center for Memory Health, to pioneering Boston’s first shelter for seniors suffering from

elder abuse and neglect, HSL is dedicated to providing seniors in the community with a wide

array of outpatient and home-based services to live their best lives. We have introduced

multiple community-focused health care services, including among others, community-based

palliative care, outpatient nutrition services, occupational therapy house calls and physical

therapy house calls.

The 2022 CHNA Implementation Plan lays out how HRC continues to invest in areas we believe

will help seniors stay healthy and independent by aligning our strategic aim - to improve the

quality of life for a growing number of seniors and their families, focusing on the

vulnerable and underserved, through direct care and services, and by generating

long-term influence through research, teaching, and advocacy efforts that will benefit

generations of seniors, providers, and caregivers.

New services and new ways to access them will help the most vulnerable seniors in the

communities we serve to live their best lives in the best place to achieve what matters most to

them and at the same time actively respond to the Attorney General’s “Building Toward Racial

Justice and Equity in Health: A Call to Action.”

The overarching goals of our 2022 Implementation Plan outline our intention to reach some of

our community’s most at-risk seniors are as follows:

● Geriatric Specialists and Services: Increase availability and accessibility of our geriatric

specialists to seniors the community

● Behavioral Health Service: Increase the availability and accessibility of our outpatient

Alzheimer’s and dementia care as well as mental health and depression services to

seniors in the community and their families

● In-Home Care: Increase types of and access to services for older adults who live at

home

● Social Determinants of Health: Focus on non-health sector services to increase health

and health equity

The 2022 CHNA Implementation Plan is structured around these identified areas of need. For

each area of need, we outline our target population, programmatic objectives, future community

activities/strategies, metrics, and community partners. The plan references HSL’s many

outpatient, in-home, and community-based services that touch more than 600 seniors daily. In

structuring and growing these services, we focused on increasing preventive care services that

offer seniors assistance with daily tasks, that increasingly include collaborations between

non-traditional partners, such as private duty services, transportation providers, post-acute care

services, and others.

For reference, the following is a brief overview of the services we provide to community-dwelling

seniors.

Outpatient Care and Services

Primary Care: Provides specialized on-site geriatric primary care to seniors, and operates

practices at NewBridge on the Charles and Orchard Cove. Practitioners in the Hebrew

SeniorLife Medical Group take a holistic approach to wellness, ensuring patients’ physical,

social, and spiritual needs are considered in care plans. Certified by the DPH and operating as

a satellite of HRC, the Medical Group offers routine exams, urgent care, psychiatric care,

podiatry, memory support consultation, chronic disease and diabetes self-management;

addresses issues such as chronic pain from arthritis, congestive heart failure, cognitive

impairments, and palliative care; and offers integrative therapies such as acupuncture and

massage.

Adult Day Health Program: Provides active, social daytime community for seniors living at home

supported by an interdisciplinary team of nursing, social work, and therapeutic recreation

professionals in a safe, structured environment. Licensed by the DPH, the program is located at

2Life Communities in Brighton and serves Russian- and Chinese-speaking seniors with

Alzheimer’s disease, other dementias, and frailty due to health problems. Staff are trained in the

Alzheimer’s Association Habilitation program.

Outpatient Therapy Services: Offers adult physical therapy, occupational therapy,

speech-language pathology, and lymphedema management. Using state-of-the-art mobility and

treatment equipment including manual therapy, joint mobilization, and therapeutic modalities to

maximize function and independence, services utilize the most up-to-date information and

treatment techniques to maximize function and independence.

Specialty Outpatient Care Services: Offers a variety of services including memory evaluations,

osteoporosis screenings, medical nutrition therapy, and audiology at HRC-Boston.

Outpatient "Get Up & Go" Senior Exercise: Offers a comprehensive fitness evaluation by

experienced exercise physiologists to develop a personalized exercise program that focuses on

progressive strength, balance, and endurance or cardiovascular training. This supervised,

medically based program is located at HRC-Boston.

HSL Off-Road Clinical Driver Evaluation Program: Designed specifically to assess the driving

needs of older adults based on current research, as well as recommendations from the

American Occupational Therapy Association, National Highway Traffic Safety Administration,

American Automobile Association (AAA), AARP, and current state regulations.

Car Fit Program: Offers seniors education on how to achieve the best fit in their personal

vehicles using everyday household objects to measure and make adjustments to keep our

roads safer for all. This national program was created in 2006 in collaboration with AAA, AARP

and the American Occupational Therapy Association.

In-Home Care in Greater Boston

Medicare-certified Home Care: Offers a comprehensive range of services to assist seniors with

their recovery following surgery, illness, a hospital stay, or to manage chronic illness.

Medicare-certified home care services include nursing, palliative care programs, physical

therapy, occupational therapy, speech and language therapy, and social work.

Home Health: Sends registered nurses and home health aides with a physician’s referral to

provide skilled care at home for the following conditions and situations: acute illness care for

falls and conditions such as diabetes, chronic heart failure, COPD, and cancer; post-surgical

care following orthopedic, spinal, heart, and other surgeries; wound care; IV therapy; physical,

occupational, and speech therapies; and palliative care. Depression screening is included in all

new patient evaluations. Additionally, HRC physical or occupational therapists can perform

home safety evaluations for seniors to ensure their environments are comfortable, secure, and

safe.

Private Care: Provides non-medical support for activities of daily living that help seniors age at

home safely.

Personal Assistance Services: Working under contracts with state-funded Aging Senior Access

Points (ASAPs) and available to income-qualified seniors, helps seniors maintain independence

in their own homes through support with housekeeping tasks and personal care. HRC partners

with the following ASAPs to serve seniors in the Greater Boston area: Boston Senior Home

Care, Central Boston Elder Services, and Ethos.

Therapy House Calls: Brings outpatient therapy to seniors at home, a particular advantage for

seniors with limited mobility and limited transportation. Offerings include geriatric physical

therapy, occupational therapy, and speech-language pathology.

HSL Hospice Care: A multidisciplinary team, comprised of medical professionals, including

physicians and nurses, in-home aides, social workers, chaplains, volunteers, families, and

friends cares for terminally ill patients and their families. They maintain the dignity, comfort, and

spiritual wellbeing of seniors and to empower them and their families to make well-informed

decisions as they move through the end-of-life experience. The majority of HSL’s hospice

clients have dementia. Services include complimentary therapy services through the generous

contributions of donors.

Community Partnerships, Education, and Awareness

As leaders in the field of senior services, HRC works hand in hand with many organizations in

Greater Boston to provide critical services to seniors in our community. From our Harvard

Medical School affiliation, to our preferred provider partnerships with acute care hospitals, to

leadership positions with professional organizations, to support of community advocacy and

senior service initiatives, we are working to promote healthy aging in Greater Boston and

beyond.

HRC works with dozens of community organizations to build on and round out their newsletters,

speaking engagements, and education fairs. We sponsor many community events in order to

help build awareness, and facilitate support groups and education for seniors and their

caregivers in the community.

HSL is proud to be a partner organization of ReiMAgine Aging, Governor Charlie Baker’s

Age-Friendly Massachusetts Action Plan.

Impact of COVID-19

The COVID-19 pandemic devastated tens of thousands of people in senior care

communities—particularly nursing homes—and changed the landscape of senior care in

Massachusetts, nationally, and globally. HSL quickly pivoted to respond to the pandemic and led

the way in determining how to provide the best possible care for seniors in this new world.

Since the coronavirus first appeared, HSL staff and volunteers worked diligently to provide our

patients and residents with the care and safety they deserve, including closing our campuses to

visitors, providing food and other basic supplies for seniors when they needed to self-shelter,

and opening what we believe was the first COVID-19 isolation unit in a U.S. long-term chronic

care hospital. We now incorporate COVID-19 as a factor in our everyday care—continuing to

develop and implement best practices in infection control to mitigate future spread and working

to address the emotional needs of patients, residents, and employees.

HSL led the way in vaccination in its senior care and living settings, introducing its COVID-19

vaccination program in December 2020 and being one of the earliest senior care organizations

to require that all employees be fully vaccinated—and subsequently boosted—against

COVID-19 as a condition of employment. The program included vaccine clinics for all patients,

residents, and employees. HSL also quickly implemented systematic testing and contact tracing

among all patient- and resident-facing staff.

Driven by our mission to care for the most vulnerable, HSL stepped forward during the

COVID-19 pandemic to lead in creating best practices for nursing homes across the country.

Massachusetts Governor Charlie Baker and Secretary of Health and Human Services Mary Lou

Sudders called on HSL in April 2020 to lead a task force that set infection control guidelines for

all 350+ nursing homes in the state and helped them develop the capabilities to meet those

objectives. This model was adopted nationally, with HSL and the Massachusetts Senior Care

Organization again leading the Commonwealth’s effort.

Throughout the pandemic, we shared our key learnings freely with senior care organizations

across the country. Our expertise is available via an online resource library that includes

materials, tools, protocols, and sample documents.

In addition, HSL’s Marcus Institute for Aging Research is partnering with institutions all over the

world to study COVID-19. For example, Marcus Institute faculty are studying the mental health

impacts of social isolation on seniors. The research is aimed at developing tools and services to

support the mental health needs of caregivers for seniors with memory concerns and utilizing a

digital-visual interface to promote social connectedness for seniors.

HSL has re-engineered our facilities and processes to prevent the spread of the virus at our six

campuses, positioning us for a post-COVID-19 future. We have enhanced our lab capabilities to

support widespread testing of our patients, residents, and staff, which will inform our research

and policy efforts by examining the spread of COVID-19 in long-term chronic care communities.

During the COVID-19 crisis we put telehealth efforts in place across many of HSL’s outpatient

services, including our Center for Memory Health, many of which are reimbursable by

MassHealth and other third-party payers. We expanded video visits into non-reimbursable areas

such as home-based palliative care and hospice. We leveraged technology to help our patients

and residents to interact with their loved ones and benefit from virtual cultural, life enhancement,

spiritual, fitness, and social activities. We have seen what a vital role technology can play in our

care and continue to invest in new ways of fostering community connections when mobility is

limited—either by public health concerns or disability.

Many seniors in our care—even those who did not contract COVID-19—experienced physical

and/or cognitive decline and struggled with mental health as a result of isolation during the

crisis. Moreover, HSL staff faced emotional hardships in the wake of COVID-19, including

depression, anxiety, and PTSD. Our in-house psychiatry and chaplaincy departments continue

to address these challenges through regular check-ins and conversations and, when necessary,

referrals for longer-term treatment plans. In response to feedback from the staff on “what

matters most to you,” we provided several supports to help reduce stress that included front-line

staff appreciation pay, hotel accommodations, food and meal deliveries, and transportation.

HSL was no exception among hospitals across the entire country when the pandemic required a

complete shift of attention and resources to protect the seniors we serve. We suspended many

outpatient services, which included outpatient therapy, therapy house calls, specialty outpatient

care, adult day health, and in-person visits to the HSL Medical Group Practices. This, combined

with the nursing shortage crisis, affected the delivery of the 2019 implementation plan. Yet we

report proudly that progress was made, albeit limited, and we are eager to approach the 2022

implementation plan in an environment that is less constrained by COVID-19.

Summary of Approach and Methods

Community Engagement Process

The Boston CHNA-CHIP Collaborative

In our last CHNA, we actively participated in the Boston CHNA-CHIP Collaborative and

incorporated its 2019 senior-oriented implications and findings into our plans. This year we did

the same.

Collaborative Community Survey

We augmented those Boston CHNA-CHIP Collaborative findings through a collaborative

community survey in partnership with Brigham and Women's Faulkner Hospital and

Massachusetts General Hospital. This survey was distributed online and in person, and

invitations to members of our local communities were distributed via social media, email, and

word of mouth. We also participated in Beth Israel Deaconess Needham listening sessions to

glean additional input.

The community survey was fielded to patients who utilize the services of HRC and Home Care

services, those who participate in Adult Day Health in Brighton, and more than 700 employees

who are residents of Boston. We also asked several community partners that serve the Boston

area to distribute the survey to potential participants. The survey was in the field for

approximately nine weeks, and the full survey can be found in Appendix A.

The HRC team took the following approach to examining the survey content:

● Made the survey in five languages (Spanish, Portuguese, Haitian Creole, Chinese

(traditional and simplified) to ensure those we serve could access and respond to it in

their native languages

● Compared our findings against the streamlined priorities and rationale that Boston

CHNA-CHIP members developed in the Boston 2019 CHNA/2020 CHIP Reports.

494 respondents were in the final sample, 82% of whom

either live, or live AND work in the community.

Respondents represented the following demographics:

Based on these exercises and the desire to

be narrowly focused on what we could

deliver in our new implementation plan, we

streamlined priorities that we felt would be

impactful, leveraged the strengths we bring

to senior health care and the community, and

reduced potential project redundancy across

HRC departments.

Quantitative Data Collection

Publicly Available Data

To identify the needs of seniors in the community, we gathered and analyzed key publicly

available community data, and we compiled and analyzed data about our service area including

demographics, social and economic factors, and access to health care. Patients come to HRC

from Boston, Brookline, Chestnut Hill, Dedham, Needham, Newton, Needham, Wellesley,

Weston, and Westwood. In recent years, these cities and towns have all been included in

multiple publically available public health assessments. As part of the HRC CHNA, the

committee reviewed a variety of data sets to identify health needs relevant to our community

and target population. All data sources have been noted within the document.

Limitations

Every data source has its own set of limitations. The many data sources used in the

development of this report applied different ways of measuring similar variables. Some data are

not available by specific population groups or at a more granular geographic level due to small

sub-sample sizes. In some cases, data from multiple years may have been aggregated to allow

for data estimates at a more granular level or among specific groups. There may be a time lag

for data sources from the time of data collection to data availability, therefore the data sets may

not fully reflect recent trends in health statistics. However, the data was still valuable and

allowed for identification of health needs relative to the Commonwealth and specific

communities.

Community Resources

The CHNA committee also examined

existing medical facilities in our

community. According to U.S. News

and World Report, there are 70

hospitals in Metro Boston alone

(including Boston, Brookline,

Cambridge and Chelsea). Of these,

many are among the top ranking/high

performing facilities in the country.

From teaching hospitals to community

health centers, Boston is a

world-renowned medical destination.

The map below shows HRC facilities

as well as acute-care hospitals within a

10-mile radius. A significant number of

additional hospitals, major care

practices, and community health facilities add to the depth of medical services available in our

local communities.

With so many world-class health facilities in the Greater Boston area, patients from all over the

world come to Boston for treatment, and physicians from around the world come to train and

learn the newest techniques. Seniors in our local communities need go no further than their

Boston doorstep to leverage the world’s greatest medical minds and facilities.

Approval

For HRC’s 2022 CHNA, Mary Moscato, President, Hebrew Rehabilitation Center and Hebrew

SeniorLife Health Care Services, provided oversight and Rachel Joslin Whitehouse, Chief

Communications and Planning Officer, served as the day-to-day lead. Consistent

communication and strategic consultations between these senior leaders and members of their

teams provided the foundation for its development. HSL’s board-level Health Care Services

Committee, chaired by Julie Rosen, reviewed and granted approval in June 2022. HRC’s key

management and a list of members of the committee may be found in Appendices B and C.

Key Findings

State Population Trends

Approximately 86,367 individuals age 65 or older reside within our service area as of 2018;

across Massachusetts, those 65 or older account for 1,016,679, approximately 15% of all

residents. Each community’s seniors over age 65 represent a low of 9.5% (Allston/Brighton) to a

high of 19.9% (Westwood) of the overall community population.

Additionally, as you can

see from the chart to the

left, there is a significant

percentage of adults age

50+, with the biggest

groups falling between

50 and 65 years old,

indicating a potential

growing need for senior

housing and services,

including adult day health

and home care.

Source: World Population Review

A look at the chart to the right shows

employment projections that demonstrate the

increasing demand for the services of home

health and personal care aides through 2030.

Source: American Health Rankings Senior Report 2021

In Massachusetts, the number of home health

care workers in 2021 was 311 workers per 1,000

adults ages 65+ with a disability compared to

157 in 2018. Source: U.S. Bureau of Labor Statistics

Our senior populations are projected to

grow, and will need an increasing

amount of services.

Community Survey Trends

When asked to “Select the top 3 areas

that hospitals should focus on to make

your community healthier,” respondents to

the community survey indicated several

areas of importance. The red items

denote particular areas that HRC plans to

address in its 2022 implementation plan.

Language

Our survey examined the languages in our local

communities by asking “What is the primary

language(s) spoken in your home?” By

understanding our market, HRC can develop

specific programs and services that map to

individuals, not only by age or general location, but

also by the availability of language services to

community dwelling seniors that may affect health

outcomes.

Our diverse employee and patient population

underscores the need to tailor services to

non-English speaking seniors, as well as HRC’s

Haitian-Creole and Russian-speaking employees.

We will continue to offer targeted services to these

populations, such as our free interpreter services

to all non-English speaking seniors who are

receiving services through HRC outpatient care,

Home Care, Adult Day Health, and our LTCH

Bilingual Services Program.

Food Access

Responses to the community survey question “What

are the main challenges you are experiencing due to

COVID-19?” revealed that hunger/food insecurity was

ranked number one. This is supported by key

informant interviews and low-income focus group

participants across neighborhoods who discussed the

challenge of not having enough money to afford the

food they and their families needed, especially in light

of recent inflation.

Feeding America’s The State of Senior Hunger in America 2019 shows that “food insecure

seniors consumed lower quantities of key nutrients..than food secure seniors. In addition, for a

wide array of health outcomes, food insecure seniors were worse-off than food secure seniors.

Food insecure seniors were more likely to have depression (262%), asthma (78%), diabetes

(74%), and congestive heart failure (71%).” Source: Feeding America 2019 Executive Summary

Not surprisingly, seniors

who are people of color,

live below the poverty

line, or have disabilities

are disproportionately

impacted by food

insecurity. Forcing

seniors with limited

incomes to choose

between food, housing,

medical or other bills

requires trade offs that

can lead to or worsen

food insecurity.

Access to Care and Transportation

Access to comprehensive, quality health care services is important for promoting and

maintaining health, preventing and managing disease, and reducing the chance of premature

death. In particular, transportation barriers can lead to rescheduled or missed appointments,

delayed care, and missed or delayed medication

use. These consequences may lead to poorer

management of chronic illness and thus poorer

health outcomes. As indicated above in community

survey trends, 14% of respondents chose

transportation among the “top 3 areas that hospitals

should focus on to make your community healthier.”

Furthermore, when specifically asked “What barriers,

if any, prevent you from getting needed health care?”

15% of respondents answered transportation.

Respondents also responded favorably that they

would benefit from and utilize a mobile health unit as

demonstrated by their answers to: “What types of

health care services or resources would you seek for

yourself or family on a mobile health van in your

community?”

Brain Health/Dementia

Among mental health concerns, stress, anxiety, and depression were the most frequently cited

challenges among Boston residents. Community suggestions to address mental health issues

include investing in more mental health supports. While HRC’s Department of Medicine offers

psychiatric and psychological services for seniors, one of our most unique areas of focus is

sustaining brain health and offering resources and support to individuals experiencing memory

loss - which may also include those with diagnoses of Alzheimer’s disease and other dementias

- and their families and caregivers. Pre-pandemic, dementia was the nation’s leading health

crisis; the subsequent isolation of older adults has only made it worse. We will be dealing with

the lingering effects of the pandemic for many years to come. Consider these statistics from the

Alzheimer’s Association. Source: Alzheimer’s Association MA State overview

● 130,000 people aged 65 and older are living with Alzheimer’s in Massachusetts.

● 9.3% of people aged 45 and older have subjective cognitive decline.

● 284,000 family caregivers bear the burden of the disease in Massachusetts.

● 411 million hours of unpaid care provided by Alzheimer’s caregivers.

● $8.7 billion is the value of the unpaid care.

● $1.7 billion is the cost of Alzheimer’s to the state Medicaid program

Furthermore, in the Alzheimer’s Association’s “Special Report: More Than Normal Aging:

Understanding Mild Cognitive Impairment,” the following facts are noted about caregivers.

Source: Alzheimer’s Association

● The prevalence of depression is higher among dementia caregivers (30% to 40%) than

other caregivers, such as those who provide help to individuals with schizophrenia (20%)

or stroke (19%).

● The prevalence of anxiety among dementia caregivers is 44%, which is higher than

among caregivers of people with stroke (31%).

These numbers show that a public health approach is necessary to lessen the burden and

enhance the quality of life for those living with cognitive impairment and their families.

Community Health Priorities Implementation Plan

2019 Summary

The 2019 HRC CHNA priorities were: 1) to reach some of our community’s most at- risk seniors,

including those experiencing abuse and neglect and/or suffering from dementia and behavioral

health issues; 2) to provide access to the geriatric-specific care and services available in

Boston, whether at HRC or our sister health care organizations, specifically in the following

areas:

● Access to Geriatric Specialists: Increase availability and accessibility of our geriatric

specialists and the ways seniors in the community can access them.

● Behavioral Health: Increase the availability and accessibility of outpatient Alzheimer’s

care as well as mental health and depression services for seniors who live in the

community and their families.

● Financial Security: Prevent the exploitation of seniors for financial gain and increase

awareness of and access to Financial Assistance Programs for community dwelling

seniors.

● Housing Affordability: Create a replicable model of senior supportive housing with

affordable services.

● Closing Racial and Ethnic Disparities that Exist in Health Care: Increase the

availability of linguistic services to community dwelling seniors. Increase the training of

HSL staff in best practices to address cultural barriers.

Metrics and status on each of these priorities are described in the 2019 Community Health

Needs Assessment Implementation Plan Results (Appendix D).

Defining HRC Priorities

In determining priorities, the CHNA committee considered the degree of community need for

additional resources, our ability to meet that need through our experience, expertise, and

programming, and the capability of other medical and hospital organizations to meet that same

need.

The CHNA committee determined that its priority should be to reach some of our community’s

most at-risk seniors and to provide access to the geriatric-specific care and services they need,

whether at HRC or our sister health care organizations, specifically in the following areas:

● Access to Geriatric Specialists: Increase availability and accessibility of our geriatric

specialists and the ways seniors in the community can access them.

● Behavioral Health: Increase the availability and accessibility of outpatient Alzheimer’s

and dementia care for seniors who live in the community and their families.

● In Home Health: Expand availability to health and wellness interventions by offering

more entry points to meet a senior care expert.

● Social Determinants of Health: Improve health and reduce longstanding disparities in

health and health care by reducing the impact of the following social determinants: food

insecurity, transportation challenges, language barriers, and domestic abuse.

Metrics and status on each of these priorities are described in the 2022 Community Health

Needs Assessment Implementation Plan (Appendix E).

Appendices

Appendix A: 2022 Community Health Survey

Community Health Survey

Brigham and Women's Faulkner Hospital and Massachusetts General Hospital, hospitals in the

Mass General Brigham system (MGB), are conducting a community health assessment to

explore what matters most to people in Boston. The purpose of this survey is to hear directly

from community members like you. The results of this survey will be analyzed and shared back

with the community and will help us to take action to positively change the factors that

influence people’s health.

Please read this important information before you begin the survey.

● This survey will take approximately 5-10 minutes to complete.

● If you do not feel comfortable answering a question, you may skip it.

● Taking this survey will not affect any services that you receive.

● This survey is anonymous.

● You will have the option at the end of the survey to enter a drawing for 1 of 5 $100 gift

cards, in appreciation of your participation. The contact information you provide to be

entered into the drawing will not be attached to your survey responses in any way.

● If you have any questions about this survey, please contact Kelly Washburn at

[email protected]d.edu

Your Community

1. Please enter the zip code of the community in which you spend the most time?

2. Please select the response(s) that best describes your relationship to the community:

* I live in this community

* I work in this community

3. Select the top 3 areas that hospitals should focus on to make your community

healthier.

* Affordable childcare

* Affordable and reliable internet

* Mental health services

* COVID-19 pandemic (testing, vaccinations, information, supplies, etc.)

* Food insecurity

* Substance misuse and the opioid crisis

* Transportation

* Career training for quality jobs

* Education supports and activities for youth

* Housing stability and homeownership

* Improved care for medical conditions, such as heart disease, cancer, diabetes, etc.

* Neighborhood safety and violence

* Small business support

* Other, please specify: _______________________________

4. Of the above top 3 areas you selected above, which is most important to you?

5. Please share any specific ideas or suggestions you have on how hospitals can

address your top priority.

6. What are the main challenges you are experiencing due to COVID-19? Please

select all that apply.

* Access to food

* Access to medication

* Broadband/Internet or computer

* Educational opportunities

* Fitness and physical wellbeing

* Housing

* Paying for utilities, rent, other supplies

* Safety

* Social isolation/mental and emotional wellbeing

* Spiritual wellbeing

* Transportation

* Unemployment

* Other, please specify: ___________________________

Your Health Care

7. Where do you primarily receive your routine health care? Please choose one.

* A doctor's office

* A public health clinic or community health center

* Urgent care provider

* A hospital emergency room

* No usual place

* Other, please specify: ________________________

8. What barriers, if any, prevent you from getting needed health care? Please select all

that apply.

* Fear or distrust of the health care system

* Not enough time

* Insurance issues

* No providers or staff speak my language

* Can’t get an appointment

* Cost

* Concern about COVID exposure

* Transportation

* Other, please specify: ______________

* No barrier

9. What types of health care services or resources would you seek for yourself or family

on a mobile health van in your community? Please select all that apply.

* Blood pressure checks

* Cancer screenings

* Food assistance, including SNAP enrollment

* Housing resources and support

* Mental health services

* Substance use counseling

* Supplies, such as face masks and hand sanitizer

* Other, please specify: _______________________________________________

* I would not seek any health care services or resources on a mobile health van

About You

The following questions help us to better understand how people of diverse identities and life

experiences may have similar or different experiences of the community.

You may skip or leave blank any questions that you prefer not to answer.

10. How old are you? _______________ (years)

11. What is your gender identity?

* Gender queer or gender non-conforming

* Man

* Transgender

* Woman

* Prefer to self-describe: _________________

12. Which of these groups best represents your race/ethnicity? Please select all that

apply.

* American Indian or Alaska Native

* Asian

* Black or African American

* Hispanic/Latino

* Native Hawaiian or Other Pacific Islander

* White

* Other, please specify_______________

13. What is the primary language(s) spoken in your home?

14. Are you currently: (Please select one)

* Employed/self-employed full time

* Employed part time or seasonal work

* A stay at home parent or caregiver

* A student (full or part time)

* Currently out of work

* Unable to work for health reasons

* Retired

* Other, specify:__________________

Gift Card Drawing Information

If you would like to enter a drawing to win 1 of 5 $100 gift cards, please complete the form

below to tell us the best way to contact you (you can provide email and/or phone number). This

information will not be used to identify your responses to the survey. The drawing will take

place in February. Please return your completed survey and form to the place where you picked

it up. Thank you for your participation.

Gift Card Drawing Form

First Name: _______________________________

Email Address or Phone number: ________________________

Appendix B: CHNA Management Structure

President’s Oversight

Mary Moscato, President, Hebrew Rehabilitation Center and Hebrew SeniorLife Health Care

Services

As President, HRC and Hebrew SeniorLife Health Care Services, Mary Moscato draws on her

dynamic background in health care operations and management to lead the organization in its

commitment to providing the highest quality care available to seniors in Greater Boston.

Additionally, she helps develop the organization’s strategic plans in expanding its health care

services. With her executive leadership roles, both at HRC and HSL, Moscato is uniquely

qualified to bring oversight and vision to the CHNA process, as well as guidance on how best to

implement the Implementation Plan.

Clinical Advisor

Helen Chen, M.D., Chief Medical Officer, Hebrew SeniorLife

Dr. Helen Chen is Chief Medical Officer at HSL serving as senior clinical advisor and overseeing

the organization's Department of Medicine. Dr. Chen brings more than 25 years of

experience with evidence-based geriatric clinical care and training to her role along with her

long standing interest in caring for our country's growing senior population. She oversees

clinical care in all HRC long-term care programs, post-acute rehabilitation, and

community-based health care services, including home care and adult day health. As clinical

advisor in the CHNA process, Dr. Chen brings medical insights to the needs assessment

process and helps identify and guide the health care programs best suited to meet the needs of

the community.

Governance

Julie Rosen, Chair, Health Care Services Committee of the Board

As Chair, Health Care Services Committee of the Board at HSL, Julie Rosen brings more than

30 years of experience working in health care and not-for-profit organizations and associations

to the CHNA governance role. Her expertise is in building effective boards and staff, developing

and executing fundraising strategies, building organizations and brands through government,

media, and community strategies, and developing business and programmatic solutions. Her

extensive knowledge of federal and state public health policy, issues, and players lends further

credence to the expertise she brings to the HRC CHNA. Rosen is Consultant and Leader of the

Not-For-Profit Practice at WittKeiffer, a global executive search firm.

Day-to-Day Lead

Rachel Joslin Whitehouse, Chief Communications and Planning Officer

Rachel Joslin Whitehouse is Chief Communications and Planning Officer at HSL. In her

planning role, she partners with the operational leadership of HSL’s health care, senior living,

teaching, and research departments to develop strategic plans and align them with annual

operational goals.

As the day-to-day lead for the CHNA, Whitehouse leverages her planning and strategic

communications expertise to guide the gathering of research and data, as well as to serve as

the liaison to the rest of the HSL community to report on progress, findings, and observations.

Appendix C: Health Care Services Committee

Julie Rosen, Chair

Valerie Fleishman, Vice Chair

Phyllis Baron

Rev. Dr. Gloria Harris Cater

Ruth Ellen Fitch

Steven Flier, M.D.

Jonathan Freedman

Marjorie Glou

Peter Gordon

Beth Greenspan

Paul Hardiman

Jon Kingsdale

Harold Kotler

Lynda Rowe

Jeff Swartz

Lynne Wolf

Appendix D: 2019 Community Health Needs Assessment Implementation Plan Results

Appendix E: 2022 Community Health Needs Assessment Implementation Plan (English

language version)

Appendix F: 2022 Community Health Needs Assessment Implementation Plan (Spanish

language version)

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Area

Target

Population

Programmatic Objectives

Community Activities /

Strategies

Metrics and Status since 2019

Community Partners

Progressive

Community-Based

Ambulatory Care

Center

Community

dwelling Seniors

Establish an ambulatory care

cluster, where community

dwelling seniors can easily

and safely access a range of

preventative care, geriatric

medical specialties, mental

health services, and

associated care coordination

and financial services

Offer increased accessibility

to ambulatory wellness

services such as geriatric

specialty clinics, Wolk

Center for Memory Health,

rehabilitation therapies,

dental, vision, and more;

addition of an ambulatory

care procedure room

Metrics:

• Reorganize services based on current patient needs

• Augment existing personnel with new hires to add depth to the program

Status:

• Expanded fitness, nutrition, memory care services

• Collaboration with Marcus Institute

• Reorganized and hired new personnel to address new Wolk Center offerings

• Refreshed ambulatory care area (e.g., Wolk Center, PT/OT area)

• Identified new services to offer at the Wolk, such as TMS

• Began offering Wolk Center services to residents at NewBridge and Orchard Cove

• Greater access to ambulatory services for new Wolk Centers

• Promoted services via Wolk newsletter, outreach to the community (virtual

counseling sessions, podcasts and webinars, media and social media placements,

blogs, partner newsletters, etc.)

Temple Emanuel,

Age Strong

Commission, Elder

Care Alliance

Community Based

Palliative Care

Frail elders with

advancing

illness who live

in their homes

in the

community

Ensure patient has a holistic

support network and

comprehensive expertise

through team approach

• Provide services and

consultation from a

Geriatric Nurse Expert and

a Geriatrician for very frail

elders with advancing

illness who live in their

homes in the community

• Offer social worker

support to answer

questions and provide

guidance about community

resources

• Provide chaplain care for

spiritual support and

complementary therapy

services of music and

massage

Metrics:

• Hire a senior lead to develop and implement program

• Identify communities to be supported through HCBS

• Extend reach through public education and telehealth

Status:

• Hired a nurse practitioner to lead the program

• Extended reach to all communities/towns served by HCBS, all active patients of HSL

Home Health, and all HSL housing residents (excluding Jack Satter House) whose PCP

is an HSL physician and served approximately 75 individuals

• Developed new marketing and communications vehicles and built website content:

https://www.hebrewseniorlife.org/services/health-care/home-senior-care-services

• Presented at national level to Center for Advanced Palliative Care Services on:

COVID-19 Advance Care Planning with Telehealth for Long-Term Care Residents

• Adopted telehealth outreach to continue to reach seniors & their caregivers during

the pandemic

Case Management

Society of New

England Frail Elders

Conference, Aging

Life Care Association

New Wellness

Nurse Consultant

Program

Adult Day

Health

participants at

Brighton

campus

Create a safety net for

detecting early disease

exacerbation and functional

decline

• Offer nurse expertise and

teaching on medications,

health and wellness topics,

self-care, and disease

management• Offer

Wellness Nurse Consultant

program in Russian and

Chinese

Metrics:• Launch program by 2022 • Engage 2Life audience in Brighton• Russian and

Chinese populations servedStatus:• Launched program in 2021 • Currently serving

five sites for 2Life Senior Living and recently embarked with The Villages of Brookline•

Currently offering Russian bilingual services, and serving Chinese population through

specialized English services

2Life

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

HRC In-Home

Telehealth

Videoconferencing

Home Health

patients at high

risk for

rehospitalization

Enable early indication of

disease exacerbation and

improved disease

management

• Leverage telehealth unit

as a teaching tool and

outreach platform in the

community

• Shift from audio-based

option to

videoconferencing by 2020

Metrics:

• # seniors reached using telehealth

• Shift from audio-based option to videoconferencing

Status:

• Reached 30-45 seniors using service-revealed diagnoses

• Hired New Clinical Informatics staff member to lead program development

• Investigating alternative technology to optimize senior wellness in partnership with

Marcus Institute

• Shifted from audio to videoconferencing using (employed IPad apps, including

FaceTime)

Extending Therapy

House Calls

Service Area and

Programming

CCB Medical

Center Patients

Optimize seniors'

independence

• Extend clinician-led

educational sessions called

Optimizing Independence

to other senior housing

communities

• Integrate a standardized

fall prevention educational

component into treatments

for all patients with balance

disorders, prior falls, and

gait difficulty

Metrics:

• Educational session offered quarterly

• Standardized educational component for falls fully integrated into all PT treatment

plans

Status:

• Unable to offer educational sessions and standardize educational component due to

COVID-19

• Provided Therapy House Calls at non-HSL assisted living communities in Newton,

Framingham, and Milton

• Conducted one HRC Outpatient Therapy “Balance/Optimizing Independence Fairs”

in 2019 and several Zoom sessions for CCB resident

• Launched Fitness House Calls with 1:1 personal training and fitness instruction from

exercise physiology therapists

• Collaborated with Marcus Institute on home-based rehab interventions to improve

functional recovery after trans-aortic valve replacement - research completed

STEP-HI Hip

Fracture Recovery

Clinical Trial

Women age 65

and older

Test strategies that may

improve recovery after a hip

fracture

Conduct research study to

see if combining

testosterone with exercise

can lead to even greater

improvements in physical

abilities after a hip fracture

Metrics:

• Recruit participants to the study

Status:

• In process of recruiting 125 participants nationally; HSL has recruited 28 to date

• Clinical trial outreach shared with professional hospital networks throughout

Greater Boston

Beth Israel, Brigham

and Women,

Faulkner, St.

Elizabeth, Boston

Medical Center,

Tufts Medical Center

Continuing Care at

Home

Seniors at home

Meaningfully impact elders

who prefer to age in home

but can benefit from the

types of HSL services typically

offered at senior living

communities

Design and launch a

coordinated care model

serving older adults living in

their individual homes

Put on hold due to COVID-19

N/A

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Community

Education/

Awareness

Local Boston

seniors,

caregivers, and

community

partners

Raise awareness of care

options by providing

education about HRC services

Participate in local

community events

Metrics:

• # community events

Status:

• 2019 - 29 community events; 8 recorded webinars

• 2021 - 64 community events

Needham Senior

Center, Norwood

Senior Center,

Brookline Senior

Center, Mass Council

on Aging, JP@Home

Community Health

Support

Local Boston

seniors,

caregivers, and

community

partners

Equip and empower

participants to share personal

experiences and feelings,

coping strategies, or firsthand

information

Facilitate support groups

and education, offer blood

pressure and flu clinics

Metrics:

• Host support groups throughout the community

• Provide education and support through webinars and health fairs

Status:

• 2019 offered 16 Support Groups, 4 Health Fairs; 2020 offered 15 support groups

• Hosted various webinars for family members who are caregivers/supports for

seniors

• Hosted HRC Roslindale Health Fair

Temple Emanuel,

Working Daughters

Online Community,

Wellesley Senior

Center, Newton

Senior Center

Transportation

Employees,

seniors

Eliminate barriers to

employment and care related

to transportation

• Ease commute for

employees who rely on

public transportation;

research and publicize

materials related to

transportation offerings

• Co-locate services to

locations where older

adults already live or

congregate

Metrics:

• Provide transportation options to HRC campuses and ensure that information is

available to employees/public

• Provide in-home/HRC on-site opportunities for seniors to access services

Status:

• Offered HSL Shuttle service throughout day w/stops at Roslindale and NewBridge

campuses and MBTA Forest Hills Station

• Maintained current transportation offerings on HSL website and new patient

materials

• In partnership with HSL in-patient team, initiated planning and obtained financial

support for a transportation system that enables seniors to overcome transportation

barriers and access the Wolk Center for Memory Health

Commission on Elder

Affairs, City of

Boston, SCOs

(ETHOS, Senior

Whole Health, and

Commonwealth Care

Alliance)

Meals on Wheels

Seniors in

Boston age 60+

who are either

temporarily or

permanently

homebound

Provide food security to help

keep seniors in their home

Provide nutritious, kosher

meals

Metrics:

• Provide meals to Boston seniors

Status:

• Provided 500 meals provided to Boston Seniors

• Sponsored HESSCO Holiday Meals

Ethos and Springwell

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

CarFit Program

Seniors who still

drive

Increase road safety for all

Offer educational program

for seniors to check how

well their personal vehicles

“fit” them

Metrics:

• # seniors participating

• # events held

Status:

• 203 seniors participating

• 16 events across all sites since inception

• Placed media stories, blogs to promote program

AAA, AARP, and

AOTA

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Behavioral Health

Overall goal: Increase the availability and accessibility of outpatient Alzheimer’s care, as well as mental health and depression services for

seniors who live in the community and their families.

Area

Target

Population

Programmatic

Objectives

Community Activities /

Strategies

Metrics and Status Update

Community Partners

Connect

existing

services across

HSL’s

continuum of

care and in the

community

Persons with a

memory

concern or

cognitive

disorder and

their family

members

Improve care

coordination to help

relieve the burden of

care giving

Provide care, education,

and counseling

Metrics:

• Variety of methods implemented to improve care coordination

Status:

• Determined workflow of nurse practitioners a) to collaborate with primary care physicians and b) for

the interdisciplinary team at Wolk Center

• Collaboration between Wolk Center social workers and community geriatric care managers through

ongoing communication

• Collaboration between Wolk Center and senior living care teams through regular, ongoing meetings

Research

Older adults

with dementia,

mild cognitive

impairment, or

delirium

Discover new ways to

improve cognitive

function and quality of

life for older adults

experiencing cognitive

impairments through

brian stimulation, drug

trials, physical

exercise, and health

care service

interventions.

• Conduct clinical trials;

Improve the ability of

health care systems to

care for people with

cognitive impairments.

• Actively train next

generation of

researchers

Metrics:

• # of clinical trials conducted

• # of post-doc scientists trained

Status:

• Conduct 6 clinical trials of drugs, brain stimulation, education, health care services, physical activity,

and environmental temperature to improve cognition and quality of life in older adults with cognitive

impoairments.

Metrics:

• Training 5 postdoctoral scientists to conduct research and clinical trials focused on improving

cognitive impairments in older adults. See our website for more information:

https://www.marcusinstituteforaging.org/

Senior Housing

facilities operated by

Hebrew SeniorLife,

and - ADD R3 sites.

Home Care

Older adults in

Greater

Boston’s

communities

Reduce severity of

depressive symptoms

and improve overall

health

Expand HSL’s “Making

Real Progress in

Emotional Health”

(MARPEH) program to

HSL Home Care

Metrics:

• % patients receiving depression assessment

Status:

• 100% home care patients receive depression assessment on admittance

In-Community

Support

CCB seniors

Reduce severity of

depressive symptoms

and improve overall

health

Explore ways to extend

the reach of mental

health and depression

services

Metrics:

• # new approaches to reach more people

Status:

• Full time social worker who provides psychotherapy

• Doubled number of psychiartry hours from 4 to 8 hours/week

Brookline Mental

Health Center (BMHC)

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Housing Affordability

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Area

Target Population

Programmatic Objectives

Community Activities /

Strategies

Metrics and Status Update

Community

Partners

Right Care, Right Place,

Right Time: Effectively

Integrating Senior Care and

Housing (R3 Initiative)

Seniors in HSL's affordable

housing with supportive

services

Clearly demonstrate a best-

practice model that redefines and

integrates senior affordable

housing and health care for the

overall benefit of seniors, with an

eye toward creating a sustainable,

replicable national model that

improves quality of care and

reduces costs

Conduct full evaluation to

measure the impact of the

model on health care

spending and quality of life

Metrics:

• Full evaluation complete

Status:

• Dramatic reductions in emergency department

trips (19%) and revisits (24%)

• Lower inpatient hospitalization rates (16%), days

(25%), and payments (22%)

• Increased engagement in self-care and

satisfaction with the program, as reported by

residents

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Financial Security

Overall goal: Prevent the exploitation of seniors for financial gain and increase awareness of and access to Financial Assistance Programs for

community dwelling seniors.

Area

Target

Population

Programmatic

Objectives

Community Activities / Strategies

Metrics and Status Update

Community Partners

Financial Assistance

Community

dwelling

seniors

Increase access

to care through

education and

assistance to

financial

programs

Work to ensure that seniors in the communities we

serve are aware of this program

Metrics:

• # of placements on HSL communications channels

Status

2 blog posts offering tips for avoiding scams:

https://www.hebrewseniorlife.org/blog/tips-avoid-coronavirus-scams-

targeting-seniors

https://www.hebrewseniorlife.org/blog/7-ways-help-prevent-seniors-

falling-victim-scams

Protecting Seniors

Seniors

who are

victims of

elder

abuse and

neglect

Combat the

incidence of

elder abuse in

Massachusetts

• Offer short-term care and shelter within existing

HSL communities to seniors who are suffering from

abuse or neglect, along with access to legal,

financial, mental health and other needed support

services

• Collaborate with community partners as well as

educate the public through programming and

communication vehicles such as HSL newsletters,

our blog, and social channels

Metrics:

• # of seniors sheltered

• # of educational offerings

Status:

• 1 senior sheltered

• 1 educational offering

• Promote World Elder Abuse Awareness Day post on social

Cambridge-Somerville

Elder Services; Jewish

Family & Children’s

Services; Greater

Boston Legal Services

APPENDIX D

Hebrew Rehabilitation Center 2019 Community Health Needs Assessment Implementation Plan Results

Closing Racial and Ethnic Disparities that Exist in Health Care

Overall goal: Increase the availability of linguistic services to community dwelling seniors. Increase the training of HSL staff in best practices

to address cultural barriers.

Area

Target Population

Programmatic

Objectives

Community Activities / Strategies

Metrics and Status Update

Community

Partners

Bilingual

Services

• Russian speaking seniors at

HRC

• Offer educational and career

advancement opportunities to

employees committed to

serving this population

Offer culturally

appropriate care and

services tailored to

their individual needs

Expand program by providing additional

services and events each year, such as

concerts and speakers, with a variety of

programs available for all cognitive levels

Metrics:

• Offer weekly programming to patients through life enhancement

and expressive therapies

• Leverage technology to keep patients engaged

Status:

• Installed technology that allowed for patients to engage in live-

streamed events at least twice a week during pandemic

• Music and memory program continues throughout the pandemic

in patient rooms and introduction of 4 listening stations on each unit

Community

Events

Russian-speaking and other

non-English speaking seniors

Actively address the

special needs for this

population

• Explore ways to extend linguistic and

cultural services

• Strengthen relationship with professional

providers in the community

• Cultivate and grow the donor base by

attending community events

Metrics:

• Offer interpreter services

Status:

• Increased number of per-diem interpreters, written and oral, to

meet increased demand; 2 full time interpreters on staff and

increased utilization of Spanish speaking intepreter

• Added annual LMS module and trained clinical team on

appropriate documentation for patients who use interpreter services

• Conducted process improvement that resulted in 1) conducting

surveymonkey for users of services with higher response rate, 2)

enhanced existing dashboard, and 3) streamlined cross-

departmental coordination of interpreter requests/utilization across

three campuses

Know our

Seniors

• HRC LTCC patients

• Holocaust survivors

• Brandeis students

Connect more deeply

through oral histories

• Offer Brandeis University oral history

project

• Research and explore Hukulah fund, a

German government-funded program

Metrics:

• # of years oral history project offered

• Hukulah fund research complete

Status:

• Offered in-person oral history project 2019, 2020; shifted to letter-

writing correspondence model in 2021 due to COVID and culminated

in a poster display

• Hukulah fund research suspended due to COVID

Brandeis

University

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Area

Target

Population

Programmatic Objectives

Future Community Activities / Strategies

Future Metrics

Community

Partners

Outpatient

Therapy

Seniors at

home who

need rehab

services

Offer HRC Rehab virtual visits

for patients who are better

served to receive therapy at

home

• Pilot virtual reality system to deliver therapeutic interventions

• Offer remote therapeutic monitoring applicability and usability

• Incorporate therapy assessments for fall risks as part of assisted living

application

• Determine best practices for falls prevention in assisted living settings and

apply to other facilities

• Collaborate with Marcus Institute on Pilot and Feasibility Study for Multi-

Component Prehabilitation Program for High-Risk Older Adults Undergoing

Major Elective Surgery

• VR pilot complete

• # users on remote

therapeutic monitoring

• Assisted Living application

therapy assessments in

place

• Production of best

practices document and #

other facilities utilizing

practices

• Feasibility pilot complete

XR Health

STEP-HI Hip

Fracture

Recovery

Clinical Trial

Women age 65

and older

Through collaboration

between Marcus Institute and

rehab, test strategies that may

improve recovery after a hip

fracture, specifically whether

combining testosterone with

exercise can lead to even

greater improvements in

physical abilities

• Continue to recruit participants

• Conduct ongoing study of intervention

• Continued outreach to professional hospital networks throughout Greater

Boston

• Publish and promote results

• # participants recruited to

the study to date

• # of publications that

promote results

Beth Israel,

Brigham and

Women, Faulkner,

St. Elizabeth,

Boston Medical

Center, Tufts

Medical Center

CarFit

Program

Seniors in

surrounding

communities

Increase road safety for all

Offer educational program for seniors to check how well their personal

vehicles “fit” them

• # seniors participating

Therapy

House Calls

Seniors living

at home

Optimize seniors'

independence through Service

Area and Programming

• Extend educational sessions led by clinicians called Optimizing

Independence to other senior housing communities

• Gait Speed Testing to assess impact of pandemic on function

• Increase # of seniors impacted by our service delivery

• # of educational sessions

offered

• # participants of Gait

Speed Testing

• % increase of seniors

impacted by service delivery

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Outpatient

Nutrition

Services

Seniors in

surrounding

communities

and HSL

employees

Raise awareness and provide

nutrition education for elders

in the community

• Increase awareness of nutritional services at HSL by working with R3 and

marketing teams to provide presentation on topics such as diabetes

management, hypertension, healthful eating, and how to eat nutritionally

when financially insecure at Needham, Brookline, and Jamaica Plain Senior

Centers

• Offer 1:1 counseling w/Medical Nutrition Therapy (MNT) for seniors in the

community, HSL seniors from all sites, and HSL employees

• Initiate group education for seniors or employees as alternative way to

conduct nutritional counseling on topics such as: diabetes, cardiac, and

weight management

• Offer nutritional counseling sessions for Harvard-Pilgrim insured employees

via Preventative Health MNT and coordinate with Livewell to earn

participation points

• # employee clients

• # of community clients

• # of nutritional groups

• # presentations in the

community

• # hours spent on research

• Listing of MNT client

referral sources

Senior Centers,

Ethos, JP at Home

Dietetic

Internship

Seniors in

surrounding

communities

and HSL

employees

Raise awareness and provide

nutrition education for elders

in the community

• Conduct clinical dietary intern rotations to provide geriatric clinical

nutrition, dietary counseling, and support

• # seniors served

Senior Centers,

Ethos, JP at

Home,Brigham &

Women's Faulkner

Hospital, Pam

Health, Functional

Nutrition,

Community

Servings, and

others

Community

Education/

Awareness

Local Boston

seniors,

caregivers, and

community

partners

Raise awareness of care

options by providing education

about HRC services

• Offer public caregiver support group

• Sponsor memory cafe to the public

• Sponsor community events and forums

• # public caregiver support

group

• # memory cafes to the

public

• # community events and

forums

Temple Emanuel

and other

community

organizations

Get up And

Seniors in

surrounding

communities

Provide individualized and

supervised fitness and

strengthening programs for

seniors in the area at a reduced

cost

Expand program to more seniors through more outreach

• Scores on SPPB, Gait

Speed to measure

pandemic's impact on

function

• % increase participant

volume

JP @ Home, Ethos,

OP Therapy

Services Referrals

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Access to Geriatric Specialists

Overall goal: Increase availability and accessibility of our geriatric specialists and the ways seniors in the community can access them.

Outpatient

Therapy

Specialty

Certifications

Geratric

specialists at

HRC

Increase number of specialty

certifications to meet diverse

needs in the aging senior

population

• Increase awareness of opportunities for community access to specialty

certifications in collaboration with the marketing department

• # new certifications for

the following specialties:

Lymphedema, Hand

Therapy, Certified Geriatric

Specialist, Orthopedic

Certified, LSVT, Functional

Medicine Certified, Driver

Safely, Vestibular, Wound

Care, Pilates, Tai Chi, Pelvic

Floor, Vital Stim

• Patient satisfaction

measures

• # specialty treatment

plans

Health providers in

the area

Progressive

Community-

Based

Ambulatory

Care Center

Seniors in

surrounding

communities

Offer increased accessibility to

HRC's ambulatory care cluster,

where community dwelling

seniors can easily and safely

access a range of preventative

care services

• Offer increased accessibility to ambulatory wellness services through

increased marketing and use of HRC Transportation program

• Patient satisfaction

measures

• % increase patient volume

for following services: Wolk

Center for Memory Health,

Physical Therapy,

Occupational Therapy,

Speech Language Pathology,

Audiology, OP Nutrition

Services, Bone Scan, OP

Modified Barium Swallows,

Shoe and Brace Clinics

Memory

Health

People living

with cognitive

symptoms or

disorders at

any stage - and

their families

and caregivers

Provide comprehensive

outpatient care related to

brain health, cognitive and

behavioral problems, and

memory loss, whether due to

Alzheimer’s disease, other

dementias, or other

neurological or psychiatric

conditions

• Program expansion to HSL housing sites clinics and other senior living sites

• Reach more seniors through mobile van concept

• Assessment & Diagnosis including neurology, psychiatry, neuropsychology,

and geriatric specialists

• Clinical Treatment including the opportunity to participate in leading edge

research

• Initiate brain health programming and to reach seniors in their residence as

part of their wellness plan

• # new HSL housing sites

clinics and other senior

living sites reached

• # seniors reached through

mobile van concept

• # seniors reached at-home

for brain health

programming

• # diagnostic procedures

performed

• % increase of new patient

volume and clinic visit

targets

• # functional assessments

conducted

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Behavioral Health

Overall goal: Increase the availability and accessibility of outpatient Alzheimer’s and dementia care for seniors who live in the community and

their families.

Area

Target

Population

Programmatic Objectives

Future Community Activities / Strategies

Future Metrics and Status Update

Community

Partners

Wolk

Center for

Memory

Health

Families and

patients at any

stage of brain

health/memory

loss

Help individuals maintain the

highest possible level of brain

function as they age—and

provide the family and caregiver

support that is critical to

achieving the best long-term

outcomes

• Resources and Support for Living with Dementia

including support groups, personalized resource

planning, and individual and family counseling

• Expand family caregiver program services

• Expand customized support group offerings (examples:

spouses, newly diagnosed individuals/families)

• Expand use of TMS treatment programming beyond

singular diagnosis of depression

• Use of telehealth interface with patients/caregivers

• # caregivers connected with resources/support

• # of new services/resources offered to family

caregivers and # of caregivers served

• # new, customized support group offerings

• Use of TMS treatment programming beyond singular

diagnosis of depression

• % increase of of telehealth use with

patients/caregivers

• # seniors reached at-home for brain health

programming

• # of cross team referrals and external referrals

• # Blog posts

Psychiatry

Division

Patients and

families

affected by

dementia

Improve identification of /

coordination of services for

patients and families affected

by dementia

• Initiate scheduled monthly meetings between Wolk

and Psychiatry to review identified clients and coordinate

services

• # clients referred to Wolk by Psychiatry

• # clients referred to Psychiatry by Wolk

Psychiatry

Division

Patients whose

mobility

challenges limit

access to

behavioral

health care

Increased access to behavioral

health services through use of

telehealth for clients whose

mobility challenges would

otherwise limit access

• Enable all behavioral health clinicians to implement

telehealth

• Provide clients technical support necessary to enable

them to use telehealth services

• % clinicians telehealth enabled

• # of patients receving behavioral health services via

telehealth

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

In Home Health

Overall goal: Expand availability to health and wellness interventions by offering more entry points to meet a senior care expert.

Area

Target Population

Programmatic

Objectives

Future Community Activities / Strategies

Future Metrics

Community

Partners

In-Home Telehealth

Videoconferencing

Home Health

patients at high

risk for

rehospitalization

Enable early

indication of disease

exacerbation and

improved disease

management

• Explore technology use options, including fall detection,

for seniors residing in community

• Institute methodology to capture SDOH data as part of

senior care planning

• Technology use option exploration complete and,

based on findings, viable options being

pursued/implemented

• Methodology established and implemented/ SDOH

data capture in progress

Community Based Palliative Care

Frail elders with

advancing illness

who live in their

homes in the

community

Ensure patient has a

holistic support

network and

comprehensive

expertise through

team approach

• Apply for Medicare Part B billing status which will allow

for reach to seniors beyond those currently being served

by HSL home health

• Reinvigorate community based educational

programming in post pandemic era

• Application submission for Medicare Part B billing

status

• Assuming approval received, reach extended

beyond HSL home health clients to 7 patients in year

1, 12 patients in year 2

• # community-based education efforts

(presentations, webinars, blogs, social media)

• # presentations to Case Management Society of

New England Frail Elders Conference, Aging Life Care

Association NE

New Wellness Nurse Consultant

Program

Residents in HSL

senior living

communities and

seniors using HSL

private pay

services

Create a safety net

for detecting early

disease

exacerbation and

functional decline

• Expand reach to HSL senior living and HSL private pay

services

• # new senior living sites served

• # new people served HSL private pay services

2Life

Communities

APPENDIX E

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Social Determinants of Health

Overall goal: Improve health and reduce longstanding disparities in health and health care by reducing the impact of the following social

determinants: food insecurity, transportation challenges, language barriers, and domestic abuse.

Area

Target Population

Programmatic Objectives

Future Community Activities / Strategies

Future Metrics

Community

Partners

Hunger/Nutrition

Seniors in the greater

Boston area

To provide high quality,

nutritionally sound, cost

effective meals through Meals

on Wheels (MOW)

Increase number of seniors who receive Meals on Wheels

• Provide 1800 meals per day, five days a week

Ethos,

Springwell,

Mystic Valley

Transportation

Seniors in Greater Boston

Offer free transportation service

to limited-income, community-

dwelling seniors, including those

who are frail or critically-ill

• Offer free transportation to seniors who are living in other HSL

communities or receiving care in their homes that enables them

access to Wolk Center for Memory Health and other outpatient

services at HRC

• Increase community outreach as part of the transportation

program to ensure we are reaching seniors who would most

benefit from this service

• Seek funding to enable expansion of vehicle utilization as

“mobile clinics”

Protecting

Seniors

Seniors who are at risk

for abuse, neglect or

financial exploitation

Combat the incidence of elder

abuse in Massachusetts

• Offer shelter and victim support services to seniors who are

suffering from abuse, neglect or financial exploitation

• Collaborate with community partners to provide education

and build awareness

• Establish and facilitate multi-agency elder abuse prevention

coalitions (known as multidisciplinary teams)

• # of referrals for shelter or supportive services

• # of seniors sheltered (incl relocation to

permanent housing at HSL sites)

• # of educational offerings

• # of agencies participating in HSL-led

multidisciplinary teams

Greater Boston

Legal Services,

Jewish Family

& Children’s

Services,

various ASAPs,

various

Councils on

Aging, various

Senior Centers

Language and

cultural

sensitivity

Russian speaking seniors

in the greater Boston

area

Actively provide professional,

accurate, and culturally

sensitive translation and

interpreter services to ensure

health equity and patient-

centered care

• Publication of biannual newsletter for Russian Speaking

community at large

• Support HRC outpatient service lines with translation of

written materials and interpreter services

• # of newsletters published

• # of interpreters available to outpatient

services

• # languages offered for interpreter services

• # of translated written materials for various

HRC outpatient services

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para especialistas en geriatría

Objetivo general: Aumentar la disponibilidad y accesibilidad de nuestros especialistas en geriatría y las maneras en que los ancianos de la

comunidad pueden acceder a ellos.

Área

Población

destinataria

Objetivos programáticos

Actividades/estrategias comunitarias en el futuro

Métricas futuras

Socios de la

comunidad

Terapia

ambulatoria

Ancianos en

casa que

necesitan

servicios de

rehabilitación

Ofrecer visitas virtuales de

rehabilitación de

Hebrew Rehabilitation Center (

HRC) a los pacientes que están

mejor atendidos para que

reciban terapia en su casa

• Utilizar un sistema piloto de realidad virtual para realizar intervenciones

terapéuticas

• Ofrecer aplicabilidad y facilidad de uso de monitoreo terapéutico remoto

• Incorporar evaluaciones terapéuticas para riesgos de caídas como parte de

la aplicación en viviendas asistidas

• Determinar cuáles son las mejores prácticas para la prevención de caídas en

entornos de vivienda asistida y aplicarlas en otros centros

• Colaborar con Marcus Institute en el Estudio piloto y de viabilidad del

Programa de Prehabilitación Multicomponente (Multi-Component

Prehabilitation Program) para adultos mayores de alto riesgo que se someten

a una cirugía mayor programada

• Piloto de realidad virtual

(Virtual Reality, VR)

completo

• Cantidad de usuarios en

monitoreo terapéutico

remoto

• Implementación de

evaluaciones terapéuticas

en la aplicación en viviendas

asistidas

• Producción del

documento sobre mejores

prácticas y cantidad de

otros centros que utilizan

las prácticas

• Piloto de viabilidad

completo

XR Health

Ensayo

clínico STEP-

HI sobre

recuperación

de fractura

de cadera

Mujeres de

65 años o más

A través de la colaboración

entre Marcus Institute y la

rehabilitación, evaluar

estrategias que puedan

mejorar la recuperación

después de una fractura de

cadera, específicamente, si la

combinación de testosterona

con ejercicio puede producir

mejoras incluso mayores en las

capacidades físicas

• Continuar seleccionando participantes

• Llevar a cabo estudio de intervención continuo

• Continuar la divulgación en las redes de hospitales profesionales de todo el

Gran Boston

• Publicar y promover resultados

• Cantidad de participantes

reclutados para el estudio

hasta la fecha

• Cantidad de publicaciones

que promueven resultados

Beth Israel,

Brigham and

Women, Faulkner,

St. Elizabeth,

Boston Medical

Center, Tufts

Medical Center

Programa

CarFit

Ancianos de

comunidades

de alrededores

Aumentar la seguridad vial

para todos

Ofrecer programas educativos para ancianos, a fin de comprobar cuán bien se

“adaptan” sus vehículos personales

• Cantidad de ancianos que

participan

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para especialistas en geriatría

Objetivo general: Aumentar la disponibilidad y accesibilidad de nuestros especialistas en geriatría y las maneras en que los ancianos de la

comunidad pueden acceder a ellos.

Visitas

terapéuticas

a domicilio

Ancianos que

viven en casa

Optimizar la independencia de

los ancianos a través del área

de servicios y la programación

• Ampliar las sesiones educativas dirigidas por profesionales clínicos llamadas

“Optimización de la independencia” (Optimizing Independence) para incluir a

otras comunidades de viviendas para ancianos

• Hacer pruebas de velocidad de marcha para evaluar el impacto de la

pandemia en la capacidad funcional

• Aumentar la cantidad de ancianos impactados por la prestación de servicios

• Cantidad de sesiones

educativas ofrecidas

• Cantidad de participantes

de las pruebas de velocidad

de marcha

• Aumento del % de

ancianos impactados por la

prestación de servicios

Servicios

nutricionales

ambulatorios

Ancianos de

comunidades

de alrededores

y empleados de

Hebrew SeniorL

ife (HSL)

Generar conciencia sobre

nutrición y educar en nutrición

a los ancianos de la comunidad

• Aumentar la conciencia sobre los servicios nutricionales de HSL mediante el

trabajo con equipos de comercialización y de la iniciativa “Atención correcta,

lugar correcto, momento correcto” (Right Care, Right Place, Right Time; R3)

para presentar temas, como control de la diabetes, hipertensión,

alimentación saludable y cómo comer de manera nutritiva cuando se está

poco seguro financieramente en centros de ancianos de Needham, Brookline

y Jamaica Plain

• Ofrecer asesoramiento individualizado con terapia médica nutricional

(Medical Nutrition Therapy, MNT) a ancianos de la comunidad, ancianos de

HSL de todos los centros y empleados de HSL

• Iniciar sesiones educativas grupales para ancianos o empleados como una

manera alternativa de dar asesoramiento nutricional en temas, como por

ejemplo: diabetes, enfermedades cardíacas y control de peso

• Ofrecer sesiones de asesoramiento nutricional a empleados con seguro de

Harvard-Pilgrim a través de MNT de salud preventiva y coordinar con Livewell

para ganar puntos por participación

• Cantidad de clientes

empleados

• Cantidad de clientes de la

comunidad

• Cantidad de grupos de

nutrición

• Cantidad de

presentaciones en la

comunidad

• Cantidad de horas

dedicadas a investigación

• Listado de fuentes de

derivación de clientes de

MNT

Centros de

ancianos, Ethos, JP

at Home

Pasantía en

dietas

Ancianos de

comunidades

de alrededores

y empleados de

Hebrew SeniorL

ife (HSL)

Generar conciencia sobre

nutrición y educar en nutrición

a los ancianos de la comunidad

• Dirigir rotaciones internas de nutrición clínica para dar atención en nutrición

clínica geriátrica, y asesoramiento y apoyo en nutrición

• Cantidad de ancianos que

se atienden

Centros de

ancianos, Ethos, JP

at Home,

Brigham &

Women's,

Faulkner Hospital,

Pam Health,

Functional

Nutrition,

Community

Servings y otros

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para especialistas en geriatría

Objetivo general: Aumentar la disponibilidad y accesibilidad de nuestros especialistas en geriatría y las maneras en que los ancianos de la

comunidad pueden acceder a ellos.

Educación/c

onciencia

comunitarias

Ancianos,

cuidadores y

socios de la

comunidad del

área de Boston

Generar conciencia sobre las

opciones de atención

mediante sesiones educativas

acerca de los servicios de HRC

• Ofrecer grupo de apoyo público a cuidadores

• Patrocinar Café de los Recuerdos (Memory Café) al público

• Patrocinar eventos y foros comunitarios

• Cantidad de grupos de

apoyo públicos a cuidadores

• Cantidad de Memory

Cafés al público

• Cantidad de eventos y

foros comunitarios

Temple Emanuel y

otras

organizaciones

comunitarias

Prueba

Levántese y

ande (Get up

And Go)

Ancianos de

comunidades

de alrededores

Proporcionar programas de

estado físico y fortalecimiento

individualizados y supervisados

para ancianos del área a un

costo reducido

Expandir el programa a más ancianos a través de una mayor difusión

• Puntajes en la prueba

Batería de desempeño físico

corto (Short Physical

Performance Battery, SPPB),

velocidad de marcha para

medir el impacto de la

pandemia en la capacidad

funcional

• Aumento del % del

volumen de participantes

JP at Home, Ethos,

derivaciones de

servicios

terapéuticos

ambulatorios

(Outpatient, OP)

Certificacion

es de

especialidad

en terapia

ambulatoria

Especialistas en

geriatría de

HRC

Aumentar la cantidad de

certificaciones de especialidad

para satisfacer las distintas

necesidades de la población de

ancianos

• Aumentar la conciencia sobre las oportunidades de acceso comunitario a las

certificaciones de especialidad con la colaboración del departamento de

comercialización

• Cantidad de nuevas

certificaciones para las

siguientes especialidades:

linfedema, terapia de

manos, especialista con

certificación en geriatría,

certificación en ortopedia,

tratamiento de voz Lee

Silverman (Lee Silverman

Voice Treatment, LSVT),

certificación en medicina

funcional, conducción

segura (Driver Safely),

sistema vestibular, cuidado

de heridas, pilates, tai chi,

suelo pélvico, sistema

VitalStim®

• Medidas de satisfacción

del paciente

• Cantidad de planes de

tratamiento de

especialidades

Proveedores de

atención médica

en el área

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para especialistas en geriatría

Objetivo general: Aumentar la disponibilidad y accesibilidad de nuestros especialistas en geriatría y las maneras en que los ancianos de la

comunidad pueden acceder a ellos.

Centro

progresivo

de atención

ambulatoria

de la

comunidad

Ancianos de

comunidades

de alrededores

Ofrecer una mayor

accesibilidad al conjunto de

atención ambulatoria de HRC,

donde los ancianos que viven

en comunidad puedan acceder

de manera fácil y segura a

diversos servicios de atención

preventiva

• Ofrecer una mayor accesibilidad a los servicios de bienestar ambulatorios a

través de mayor comercialización y uso del programa de transporte de HRC

• Medidas de satisfacción

del paciente

• Aumento del % del

volumen de pacientes para

los siguientes servicios:

Wolk Center for Memory

Health (Centro Wolk para la

salud de la memoria),

fisioterapia, terapia

ocupacional,

fonoaudiología, audiología,

servicios nutricionales

ambulatorios, gammagrafía

ósea, tránsito esofágico

modificado para pacientes

ambulatorios y clínicas

ortopédicas

Salud de la

memoria

Personas que

tienen síntomas

o trastornos

cognitivos en

cualquier

etapa, y sus

familias y

cuidadores

Proporcionar atención

ambulatoria integral

relacionada con la salud del

cerebro, los problemas

cognitivos y conductuales y la

pérdida de la memoria, ya sea

a causa de la enfermedad de

Alzheimer, otras demencias u

otras afecciones neurológicas

o psiquiátricas

• Programar la expansión de las clínicas de los centros de viviendas de HSL y

otros centros de viviendas para ancianos

• Llegar a más ancianos a través del concepto de furgoneta móvil

• Hacer evaluaciones y diagnósticos, por ejemplo, de especialistas en

neurología, psiquiatría, neuropsicología y geriatría

• Dar tratamiento clínico, que incluye la oportunidad de participar en

investigaciones de vanguardia

• Iniciar programas de salud del cerebro y llegar a la casa de los ancianos

como parte de su plan de bienestar

• Cantidad de nuevas

clínicas de los centros de

viviendas de HSL y otros

centros de viviendas de

ancianos a los que se llega

• Cantidad de ancianos a los

que se llega a través del

concepto de furgoneta

móvil

• Cantidad de ancianos a los

que se llega a su casa en los

programas de salud del

cerebro

• Cantidad de

procedimientos de

diagnóstico realizados

• Aumento del % del

volumen de nuevos

pacientes y objetivos de

visitas a las clínicas

• Cantidad de evaluaciones

funcionales realizadas

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para salud conductual

Objetivo general: Aumentar la disponibilidad y accesibilidad de la atención ambulatoria de la enfermedad de Alzheimer y la demencia para

ancianos que viven en la comunidad y sus familias.

Área

Población

destinataria

Objetivos programáticos

Actividades/estrategias comunitarias en el futuro

Métricas futuras y actualización de estado

Socios de la

comunidad

Wolk

Center for

Memory

Health

Familias y

pacientes en

cualquier etapa

de salud del

cerebro/pérdida

de la memoria

Ayudar a las personas a

mantener el máximo nivel

posible de función cerebral a

medida que envejecen, y dar el

apoyo a la familia y a los

cuidadores que es fundamental

para lograr los mejores

resultados a largo plazo

• Recursos y apoyo para vivir con demencia, incluidos

grupos de apoyo, planificación de recursos

personalizados, y asesoramiento individual y familiar

• Ampliación de los servicios de programas de cuidadores

de la familia

• Ampliación de las ofertas de grupos de apoyo

personalizado (ejemplos: cónyuges, personas recién

diagnosticadas/familias)

• Ampliación del uso de programas de tratamiento de

estimulación magnética transcraneal (Transcranial

Magnetic Stimulation, TMS) además del diagnóstico

particular de depresión

• Uso de la interfaz de telemedicina con

pacientes/cuidadores

• Cantidad de cuidadores conectados con

recursos/apoyo

• Cantidad de nuevos servicios/recursos ofrecidos a

cuidadores de la familia y cantidad de cuidadores

atendidos

• Cantidad de nuevas ofertas de grupos de apoyo

personalizado

• Uso de programas de tratamiento de TMS además del

diagnóstico particular de depresión

• Aumento del % de uso de la interfaz de telemedicina

con pacientes/cuidadores

• Cantidad de ancianos a los que se llega a su casa en

los programas de salud del cerebro

• Cantidad de derivaciones entre equipos y

derivaciones externas

• Cantidad de publicaciones en blogs

División

Psiquiatría

Pacientes y

familias

afectados por la

demencia

Mejorar la

identificación/coordinación de

servicios para pacientes y

familias afectados por la

demencia

• Iniciar reuniones mensuales programadas entre el

centro Wolk y la División de Psiquiatría para revisar los

clientes identificados y coordinar los servicios

• Cantidad de clientes derivados al centro Wolk por la

División de Psiquiatría

• Cantidad de clientes derivados a la División de

Psiquiatría por el centro Wolk

División

Psiquiatría

Pacientes cuyas

dificultades de

movilidad

limitan su

acceso a la

atención de

salud

conductual

Dar mayor acceso a los servicios

de salud conductual a través del

uso de telemedicina a los

clientes cuyas dificultades de

movilidad limitarían de otro

modo su acceso

• Permitir a todos los profesionales clínicos de salud

conductual implementar la telemedicina

• Darles a los clientes el soporte técnico necesario que les

permita usar los servicios de telemedicina

• % de profesionales clínicos con telemedicina habilitada

• Cantidad de pacientes que reciben servicios de salud

conductual a través de telemedicina

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para salud en casa

Objetivo general: Ampliar la disponibilidad de las intervenciones de salud y bienestar mediante ofertas de más puntos de entrada para

reunirse con un experto en atención de ancianos.

Área

Población

destinataria

Objetivos programáticos

Actividades/estrategias comunitarias

en el futuro

Métricas futuras

Socios de la

comunidad

Videoconferencias de

telemedicina en casa

Pacientes de salud en

casa de alto riesgo

para una nueva

hospitalización

Permitir indicaciones tempranas

de la exacerbación de la

enfermedad y mejora del

control de la enfermedad

• Explorar opciones uso de tecnología,

incluida la detección de caídas para

ancianos que viven en la comunidad

• Establecer una metodología para

capturar datos de los determinantes

sociales de la salud (Social Determinants

of Health, SDOH) como parte de la

planificación de la atención de ancianos

• Exploración de opciones del uso de tecnología completa y, en

función de hallazgos, opciones viables que se

persiguen/implementan

• Metodología establecida e implementada/captura de datos de

SDOH en curso

Cuidados paliativos

en la comunidad

Ancianos debilitados

con enfermedad

avanzada que viven

en casa en la

comunidad

Garantizar que el paciente tenga

una red de apoyo holístico y

conocimientos especializados

integrales a través de un

enfoque de equipo

• Solicitar el estado de facturación de la

Parte B de Medicare que permitirá llegar

a ancianos además de los que

actualmente son atendidos por salud en

casa de HSL

• Revitalizar los programas educativos

comunitarios en la era de la

pospandemia

• Presentación de solicitud del estado de facturación de la

Parte B de Medicare

• Suponiendo que se reciba la aprobación, se ampliará el alcance

además de los clientes de salud en casa de HSL a 7 pacientes en el

año 1, 12 pacientes en el año 2

• Cantidad de iniciativas educativas comunitarias

(presentaciones, seminarios web, blogs, redes sociales)

• Cantidad de presentaciones ante la Sociedad de Administración

de Casos (Case Management Society) de la Conferencia de

Ancianos Debilitados de New England (New England Frail Elders

Conference), asociación Aging Life Care™ de New England (NE)

Nuevo programa de

enfermeras asesoras

en bienestar

Residentes en

comunidades de

viviendas para

ancianos de HSL y

ancianos que usan

los servicios de pago

privado de HSL

Crear una red de seguridad para

detectar exacerbación temprana

de la enfermedad y deterioro

funcional

• Ampliar el alcance para llegar a las

viviendas para ancianos de HSL y

servicios de pago privado de HSL

• Cantidad de nuevos centros de viviendas para ancianos que

reciben servicios

• Cantidad de nuevas personas que reciben servicios de pago

privado de HSL

2Life

Communities

APPENDIX F

Hebrew Rehabilitation Center 2022 Community Health Needs Assessment Implementation Plan

Plan de implementación para los determinantes sociales de salud

Objetivo general: Mejorar la salud y reducir las desigualdades que existen desde hace tiempo en cuanto a salud y atención médica mediante

la reducción del impacto de los siguientes determinantes sociales: inseguridad alimentaria, problemas de transporte, barreras lingüísticas y

maltrato doméstico.

Área

Población

destinataria

Objetivos programáticos

Actividades/estrategias comunitarias en el futuro

Métricas futuras

Socios de la comunidad

Hambre/Nutrición

Ancianos del

área del Gran

Boston

Proporcionar comidas de

alta calidad, muy

nutritivas y rentables a

través de Meals on

Wheels (MOW)

Aumentar la cantidad de ancianos que reciben Meals on Wheels

• Proporcionar 1800 comidas por día,

cinco días a la semana

Ethos, Springwell, Mystic Valley

Transporte

Ancianos del

Gran Boston

Ofrecer servicio de

transporte gratuito a

ancianos con ingresos

limitados, que viven en la

comunidad, incluidos

aquellos que están

debilitados o son

enfermos graves

• Ofrecer transporte gratuito a ancianos que viven en otras

comunidades de HSL o reciben atención en otros hogares que les

permite el acceso a servicios de Wolk Center for Memory Health y

otros servicios ambulatorios de HRC

• Aumentar la difusión comunitaria como parte del programa de

transporte para garantizar que se llegue a los ancianos que

obtendrían más beneficios de este servicio

• Buscar financiación para ampliar la utilización de vehículos como

“clínicas móviles”

Protección de

ancianos

Ancianos que

están en

riesgo de

maltrato,

abandono o

explotación

financiera

Combatir la incidencia de

maltrato a ancianos de

Massachusetts

• Ofrecer refugios y servicios de apoyo a ancianos que son víctimas

de maltrato, abandono o explotación financiera

• Colaborar con socios de la comunidad para ofrecer sesiones

educativas y generar conciencia

• Establecer y facilitar coaliciones de prevención de maltrato de

ancianos de varias agencias (conocidas como “equipos

multidisciplinarios”)

• Cantidad de derivaciones para refugios

o servicios de apoyo

• Cantidad de ancianos en refugios

(incluida la reubicación en viviendas

permanentes en centros de HSL)

• Cantidad de ofertas educativas

• Cantidad de agencias que participan

en equipos multidisciplinarios dirigidos

por HSL

Greater Boston Legal Services, Jewish

Family & Children’s Services, varios

puntos de acceso para ancianos

(Aging Senior Access Points, ASAP),

varios Consejos sobre Envejecimiento

(Councils on Aging), varios centros

para ancianos

Idioma y

sensibilidad

cultural

Ancianos que

hablan ruso

en el área del

Gran Boston

Prestar activamente

servicios de traducción e

interpretación

profesionales, precisos y

con sensibilidad cultural

para garantizar equidad

en salud y atención

centrada en el paciente

• Publicación de boletín informativo semestral para la comunidad

de habla rusa en general

• Líneas de apoyo de servicios ambulatorios de HRC con la

traducción de material por escrito y servicios de interpretación

• Cantidad de boletines informativos

publicados

• Cantidad de intérpretes disponibles

para servicios ambulatorios

• Cantidad de idiomas ofrecidos para

servicios de interpretación

• Cantidad de material traducido por

escrito para diversos servicios

ambulatorios de HRC