JoAnne McCarthy (left) discusses at-home senior care services with archdiocesan social worker Kelly Amenhauser. Through a unique partnership with St. Mary Medical Center in Langhorne, the Philadelphia archdiocese provides elder care tailored to seniors in lower Bucks County. (Photo by Gina Christian)

When 76-year-old JoAnne McCarthy was searching for home health care options, she didn’t have high expectations.

“’Just get me what I need’ – that’s what I felt,” said McCarthy, who resides in lower Bucks County.

McCarthy’s wariness — and weariness — were understandable. After suffering a stroke 10 years ago, she had difficulty walking. A recent fall at home, compounded by a second stroke, landed her back in the hospital at nearby St. Mary Medical Center in Langhorne.

Through St. Mary, McCarthy was able to access home health care services, enabling her to stay in the home where she has lived for the past 25 years. However, the application process for Medicaid waivers – which cover the cost of such supports – can be time-consuming, often exceeding the number of social worker visits allotted by a given insurance or health care provider.

To bridge such gaps in coverage, St. Mary (now owned by Trinity Health) tapped archdiocesan Catholic Housing and Community Services (CHCS), which currently provides a continuum of support to approximately 10,000 seniors in the Philadelphia region.

In 2015, St. Mary began providing CHCS with annual funding for a full-time social worker dedicated to assisting aging clients of the medical center. From July 2017 through June 2018, the program served 198 seniors in lower Bucks County.

Once assigned to McCarthy, CHCS social worker Kelly Amenhauser accompanied her client through the entire application process, making sure the necessary documentation was correctly filed. With her waiver in place, McCarthy was able to retain a home health care aide who now visits daily to prepare meals, assist with personal hygiene, handle light housecleaning tasks, and drive her to medical appointments.

“Applying for the home and community-based waiver service is a course of several months sometimes,” said Amenhauser. “There’s a lot of back and forth, a lot of ‘we need one more thing.’ And for someone that’s homebound, that ‘one more thing’ is a lot, but I’m able to come here, get a copy and bring it to the county assistance office.”

Amenhauser’s assistance has had a profound impact on clients like McCarthy.

“She saved my life,” said McCarthy. “I wanted to be here in my home, and I knew I couldn’t stay here by myself. My neighbors helped me, but they’re elderly too.”

The program expands the reach and service levels of health systems like St. Mary, according to Heather Huot, CHCS’s assistant director of parish and housing services.

“The partnership is both powerful and cost effective,” said Huot. “What the health system pays in funding is far outweighed by what we give them.”

Lisa Kelly, director of community health and well-being for St. Mary, described the arrangement as a “great way to connect area seniors with the support they need.”

In one case, Kelly noted, a CHCS social worker was able to gain the trust of an elderly couple who had refused assistance from local authorities concerned about their safety. Over a period of weeks, the CHCS professional visited the couple, developing a constructive dialogue that ultimately enabled them to access needed services.

Another key indicator of the program’s success is the reduced rate of rehospitalizations among clients. Of the 198 seniors that Amenhauser assisted last year, only 28 were readmitted to the hospital. While many of the rehospitalized clients would qualify for nursing homes, finding long-term care for seniors is often beyond the scope of most health care systems’ service range.

Huot also observed that nursing homes in general are not necessarily a senior’s first option, since elder service is beginning to shift away from institutional-based care towards in-home support.

“For someone who’s 90 years old, and who’s lived in the community and in their home for 60 years, it’s traumatic to leave that,” she said.

To ensure that clients are a fit for home-based care, CHCS conducts a thorough assessment that accounts for a wide range of factors, including age, length of residence, financial status and quality of housing, as well as physical, mental and emotional health.

“We often joke at our meetings how long our assessment is, but it’s about 20 pages long for a reason, because we recognize that all these elements interplay,” said Huot. “If someone doesn’t have enough money for food or for home heating, their health isn’t going to be good.”

Another advantage that CHCS offers is flexibility in its service delivery, which is offered without “rigid requirements,” Huot said. In addition to accessing support over a longer period of time, seniors referred to CHCS by St. Mary can receive care that is tailored to their individual needs.

This focused approach is one that CHCS developed as part of its parish-based senior outreach. Through that program, CHCS helps to fund the placement of elder care managers in 15 archdiocesan parishes. Last year, the parish elder care team connected more than 1,100 area seniors with a range of services.

According to the U.S. Census Bureau, seniors will outnumber children by 2030, intensifying national demand for elder care. Meeting seniors’ needs will increasingly require both health systems and agencies like CHCS to be “creative,” Huot said.

“We’ve developed a model, and we’re good at this,” said Huot, who will present an overview of the CHCS – St. Mary partnership at the annual Catholic Charities USA gathering this month in Buffalo, N.Y.

Huot added that one of the critical but often overlooked advantages of the CHCS partnership model is its ability to offset loneliness and isolation among seniors.

“Just being there to walk alongside someone goes beyond a measurable value,” she said.

McCarthy agrees, noting that she once called Amenhauser during a bout of depression and asked her to stop by the house for a visit.

“I can’t thank her enough, and she’s in my prayers every night,” said McCarthy. “It’s just not getting me services. It’s helping me; she really has helped me.”