4. Wrap Around Services Summary The TIPs team has always considered wrap around services to be foundational to the successful implementation of the TIPs program. The overarching goal of the program has been to build a holistic culture of health with our residents, and to do that we had to first understand the health status of the participants. As TIPs launched, data was gathered during intake indicating that most participants were managing multiple chronic health conditions, such as COPD, diabetes, asthma, etc. With this in mind, education around the management of chronic health conditions was an important first step in setting the stage to build a culture of health. The on-site Resident Services Coordinators engaged with Essex County Division of Senior Services and the NJ Division of Aging Services to run a six-week workshop series called “Take Control of Your Health”, aimed at managing chronic health conditions. Also, as a result of the intake data, the RSCs partnered with a local hospital used by many Grace West residents to run a diabetes education workshop. The team also discovered two unexpected challenges for participants as a result of the program intake process. First, it was observed that many of the residents were squinting or having trouble reading the intake form, even when wearing their glasses. Free vision screenings were organized by the RSCs at the same time as the telehealth screenings were taking place, to give residents updated prescriptions and advice. The second unanticipated barrier to the program was that many residents did not have working phones or phone numbers. Because telephone follow up from the nurse is an important part of the TIPs program, lack of phone access was a significant barrier to health. To address this, the on-site Resident Services Coordinators partnered with Assurance Wireless to sign participants up with free phones. This service benefitted both the townhome families and the seniors. Additional programming to build a culture of health at Grace West included nutrition programs to promote healthy eating and Zumba classes to promote movement. Fitbits were also distributed to a sample of participants to track steps taken and further motivate participants to include movement in their daily lives. In March 2020, TIPs had to pause its in-person programming due to the COVID-19 pandemic. The team had to reimagine ways to monitor and support participants in their health without being able to physically see them. Resident Services Coordinators (RSCs) and Telehealth Technician Assistants (TTAs) began contacting participants by phone to ask the five standard telehealth screening questions that had traditionally been asked at the start of each health screening. By doing this, resident well-being could be monitored, and the telehealth nurse would be able to follow up with residents to provide support and advice. Later, in a pivot to address the new challenges posed by COVID 19, the TIPs team began a pilot of “TIPs at Home.” With this program, a subset of 60 participants was provided with a blood pressure machine and a pulse oximeter that they can keep in their apartment. TTAs continued to call residents and ask not only the five screening questions, but also the vital sign readings participants were taking on their devices. With this new model, the team had a better understanding of participants’ health at home. Additionally, these readings were able to be entered into the telehealth system, to gather data and trigger alerts for the remote nurse to follow up on, thereby ensuring that residents were getting the health support and advice they needed.
4. Wrap Around Services Summary
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