Jewish Community Center with Jewish Association on Aging and Jewish Family & Children’s Service
AgeWell Pittsburgh

Description:  This collaborative provides a continuum of services and information and referral designed to keep frail seniors active and living independently in their homes.  The program serves 6,000-10,000 seniors each year without regard to religious affiliation.  Services include extensive outreach, evaluation, monitoring, and referral.  There is special focus on outreach to engage seniors ages 85+ who are most vulnerable.  United Way funding supports these services as well as the collection of evaluative data to determine the impact of the collaboration on the results achieved and how it may serve as a model for community level impact.  

The Program Serves a Population with Great Needs:  The program serves seniors age 65+, who are low-income and/or at high risk for institutionalization.  The program focuses specifically on seniors who are over age 85, exhibiting some difficulty with tasks of daily living, and/or are eligible to be placed in a nursing home as determined by the Area Agency on Aging.  Seniors reside primarily in the East End of Pittsburgh and the South Hills.

The Program Achieves Measurable Results:  During the past year, 70% of AgeWell participants maintained their level of functioning,  20% improved their functioning, and 92% of active participants avoided hospital and emergency room visits.

The Program Applies a Sound Approach:  The collaboration of three agencies has produced an information and referral telephone number and website, shared outreach strategy, shared tool for ongoing assessment, and structured mechanism for making referrals. The program’s research-based components include:  reassurance phone calls to at-risk seniors, transportation for seniors to participate in activities, financial subsidies, and in-home services for homebound seniors. The program utilizes a program-specific Protective Factors Screening tool which allows providers throughout the AgeWell network to quantify progress of participants in specific areas.

Alignment with Preferred Outcomes:

• Remain safely in home/least restrictive community setting (2,700 of 3,000 tracked, or 90%)
• Adequate/improved nutritional, health, and/or functional status (2,700 of 3,000, or 90%)

Community Outcomes:  This collaboration is a replicable model and serves a large number of frail seniors.  The Protective Factors screening tool can be utilized by other agencies to evaluate participant independence and service needs.