JSSA's Partners in Care (PIC) Program

Last year, 98 percent of PIC clients were able to remain living safely in their homes.

JSSA’s Partners in Care (PIC) program launched a decade ago under JSSA’s leadership and aims to improve the health of at-risk, lower-income adults at affordable senior communities in Montgomery County (Homecrest House and Springvale Terrace). Intensive care management is the core component of this program. Over the years, the program was expanded to include physical, speech, and occupational therapy; mental health care; nurse home visits; and in-home care – which, combined, comprehensively address vulnerable residents’ needs.

The program is offered by a collaboration of eight agencies, including JSSA. Each week, representatives from the participating agencies, along with the staff from each housing site, meet to coordinate their efforts on behalf of residents. During these meetings, they discuss mutual clients, coordinate care, and carefully track outcomes. The results - residents experience improvement in all identified areas, including fewer falls and emergency room visits – and better access to mental health, primary care, and advanced care planning.

Last year, 98 percent of PIC clients were able to remain living safely in their homes. For seven years, PIC has received generous funding from the Healthcare Initiative Foundation. This model is attracting attention. Leading Age Maryland, the state umbrella organization for senior homes, invited JSSA to present on PIC at a 2022 conference. It was a chance to connect with housing sites that may benefit from the PIC program in the future.

A resident of Homecrest House for six years, Faythe, receives care via the Partners in Care collaborative model. For instance, she gets case management and mental health support from JSSA, personal care from JSSA Homecare, physical and occupational therapy from Fox Rehabilitation, and primary care from a medical home care agency. Her care manager meets with Faythe and other residents regularly. “It is validating to see that ongoing evaluation of our program reflects positive outcomes for our participants,” says the care manager.

“These include increased levels of socialization, a decrease in falls, and high levels of participation in advance care planning.” “My care manager has a remarkable ability to go the extra yard to get things done,” says Faythe. She lists numerous examples: they identified a grant that covered the cost of personal products she was unable to afford, helped with her taxes, arranged for new eyeglasses to replace a 10-year-old prescription, and connected her to a social worker who provides her with regular therapy sessions which were especially valuable during times of social isolation.

While Faythe feels that her care manager would do anything for her, she also appreciates that they treat her with respect and encourage her to do things for herself. Before, professionals and family members "would talk about me as if my mind was gone, as if I wasn't even in the room." JSSA, she says, is the opposite. Other Homecrest and Springvale residents echo her sentiment, acknowledging that JSSA staff bring warmth and companionship into their lives and give them a sense of dignity.

Says Marcy Hunter, Springvale Terrace executive director, “The impact PIC has had on our residents is enormous. The support means… we have a team of people that specialize in their fields and have a multitude of resources and experiences to offer our residents. We couldn't be prouder of the increased services that we are able to offer to our residents.”