Delivery of Medical and Social Services to the Homebound Elderly: A Demonstration of Intersystem Coordination. Executive Summary

摘要

The New York City Homebound Elderly project was a research and demonstration project designed to enable homebound, chronically ill, Medicare clients to maintain a satisfactory existence at home and to prevent or defer unnecessary utilization of acute and long term care institutional services. Two social services and two health care agencies served as service delivery sites, each maintaining a census of 100 clients. The primary programmatic thrusts were: interdisciplinary assessment and care planning; provision of critical service through Medicare waivers (homemaker/personal care, transportation, prescription drugs and case management); and securing needed supplementary services through the coordination of the existing health and social services network.