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TCM is a framework to improve outcomes of hospitalized older adults who are transitioning to SNF, ALFs or directly home. This resource helps understand the foundation in relation to building relationships with patient care team. It includes screening, staffing, building relationships, assessing/ managing risk, educating/promoting self management, collaborating, promoting continuity and fostering coordination

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PACE (Program of All-inclusive Care for the Elderly)

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PACE (Program of All-inclusive Care for the Elderly)

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PACE focuses on maintaining independence of older adults by allowing them to live safely in their homes instead of nursing homes. Within every PACE program is an

Interdisciplinary Team

Individualized health care plan

A PACE center: includes a doctors office, rehab gym, social work offices, and activities center

Eligibility Requirements

age 55 or older

Live in a PACE organization service area

Live in community (not nursing home)

Can live safely in the community

Local Massachusetts Resources

Middlesex & Suffolk Counties

Elder Service Plan of Cambridge Health Alliance

617-575-5850

Elder Service Plan of East Boston Neighborhood Health Center

617-568-4602

Norfolk & Suffolk Counties

Elder Service Plan of Harbor Health

617-533-2400

Upham's Elder Service Plan

617-288-0970

Essex & Middlesex Counties

Element Care

781-715-6608

Hampden, Hampshire, Middlesex & Worcester Counties

Summit ElderCare/ Fallon Community Health Plan

1-800-698-7566

Hampden & Hampshire Counties

Mercy LIFE, Inc.

413-827-4243

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The Program of All-inclusive Care for the Elderly (PACE) is administered by MassHealth and Medicare to provide a wide range of medical, social, recreational, and wellness services to eligible participants. You do not need to be on MassHealth to enroll in PACE. However, if you meet the income and asset guidelines, you may be eligible for MassHealth and MassHealth may pay your PACE premium.

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Program of All-inclusive Care for the Elderly (PACE)

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Providing a wide array of services to help participants live safely in their own homes

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ASAP helps to provide programs and services to support adults aged 60 and older, and their caregivers.

Provides following services:

Home care program

Senior nutrition program

Options counseling

Family caregiver support program

Community Transition Liaison Program

Supportive/ Congregate Housing

24 locations across the Commonwealth

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1. AgeSpan

280 Merrimack Street, Suite 400
Lawrence, MA 01843

(978) 683-7747
Toll Free: (800) 892-0890

Web: http://www.agespan.org

Areas served: Amesbury, Andover, Billerica, Boxford, Chelmsford, Danvers, Dracut, Dunstable, Georgetown, Groveland, Haverhill, Lawrence, Lowell, Marblehead, Merrimack, Methuen, Middleton, Newbury, Newburyport, North Andover, Peabody, Rowley, Salem, Salisbury, Tewksbury, Tyngsboro, West Newbury, Westford

2. Aging Services of North Central Massachusetts

680 Mechanic Street, Suite 120
Leominster, MA 01453

(978) 537-7411

Web: https://www.agingservicesma.org/

Areas served: Ashburnham, Ashby, Ayer, Berlin, Bolton, Clinton, Fitchburg, Gardner, Groton, Hubbardston, Lancaster, Leominster, Lunenburg, Pepperell, Princeton, Shirley, Sterling, Templeton, Townsend, Westminster, Winchendon

3. Boston Senior Home Care

89 South Street, Lincoln Plaza Suite 501
Boston, MA 02111

(617) 292-6211

Web: https://www.bshcinfo.org

Areas served: Boston neighborhoods of Beacon Hill, Boston, Charlestown, Dorchester, Downtown, East Boston, North End, South Boston, South Cove, West End

4. Bristol Aging & wellness, Inc.

1 Father DeValles Blvd., Unit 8
Fall River, MA 02723

(508) 675-2101

Web: http://www.bristolelder.org

Areas served: Attleborough, Berkley, Dighton, Fall River, Freetown, Mansfield, North Attleborough, Norton, Raynham, Rehoboth, Seekonk, Somerset, Swansea, Taunton, Westport

5. Central Boston Elder Services

2315 Washington Street
Boston, MA 02119
(617) 277-7416 Web: https://centralboston.org/
Areas served: Boston neighborhoods of Allston, Back Bay, Boston, Brighton, Fenway, Jamaica Plain, Kenmore/Fenway, Mission Hill, Roxbury, South End

6. Coastline Elderly Services, Inc.

863 Belleville Avenue

New Bedford MA 02745

(508) 999-6400

Web: https://coastlinenb.org

Areas served: Acushnet, Dartmouth, Fairhaven, Gosnold, Marion, Mattapoisett, New Bedford, Rochester

7. Elder Services of Berkshire County, Inc.

73 South Church Street
Pittsfield, MA 01201

(413) 499-0524

Web: https://www.esbci.org

Areas served: Adams, Alford, Becket, Cheshire, Clarksburg, Dalton, Egremont, Florida, Great Barrington, Hancock, Hinsdale, Lanesborough, Lee, Lenox, Monterey, Mount Washington, New Ashford, New Marlborough, North Adams, Otis, Peru, Pittsfield, Richmond, Sandisfield, Savoy, Sheffield, Stockbridge, Tyringham, Washington, West Stockbridge, Williamstown, Windsor

8. Elder Services of Cape Cod and the Islands, Inc.

68 Route 134
South Dennis, MA 02660

(508) 394-4630

Web: http://www.escci.org

Areas served: Aquinnah, Barnstable, Bourne, Brewster, Buzzards Bay, Chatham, Chilmark, Dennis, Eastham, Edgartown, Falmouth, Gay Head, Harwich, Hyannis, Mashpee, Nantucket, Oak Bluffs, Orleans, Provincetown, Sandwich, Tisbury, Truro, Wellfleet, West Tisbury, Yarmouth

9. Elder Services of Worcester Area, Inc.

67 Millbrook Street, Suite 100
Worcester MA 01606

(508) 756-1545

Web: http://www.eswa.org

Areas served: Auburn, Barre, Boylston, Grafton, Hardwick, Holden, Leicester, Millbury, New Braintree, Oakham, Paxton, Rutland, Shrewsbury, West Boylston, Worcester

10. ETHOS

555 Amory Street
Jamaica Plain, MA 02130
Web: Areas served: Boston neighborhoods of Jamaica Plain, Roslindale, West Roxbury, Hyde Park and Mattapan https://www.ethocare.org/
(617) 522-6700

11. Greater Lynn Senior Services, Inc.

8 Silsbee St.
Lynn, MA 01901

(781) 599- 0110

Web: http://www.glss.net

Areas served: Lynn, Lynnfield, Nahant, Saugus, Swampscott

12. Greater Springfield Senior Services, Inc.

66 Industry Ave.
Springfield, MA 01104

(413) 781-8800
(413) 781-0632

Web: http://www.gsssi.org

Areas served: Agawam, Brimfield, East Longmeadow, Hampden, Holland, Longmeadow, Monson, Palmer, Springfield, Wales, West Springfield, Wilbraham

13. HESSCO Elder Services

545 South Street, Suite 300
Walpole, MA 02081

(781) 784-4944

Web: http://www.hessco.org

Areas served: Canton, Dedham, Foxborough, Medfield, Millis, Norfolk, Norwood, Plainville, Sharon, Walpole, Westwood, Wrentham

14. Highland Valley Elder Services, Inc.

320 Riverside Drive Suite B
Florence, MA 01062

(413) 586-2000

Web: http://www.highlandvalley.org

Areas served: Amherst, Blandford, Chester, Chesterfield, Cummington, Easthampton, Goshen, Granville, Hadley, Hatfield, Huntington, Middlefield, Montgomery, Northampton, Pelham, Plainfield, Russell, Southampton, Southwick, Tolland, Westfield, Westhampton, Williamsburg, Worthington

15. LifePath, Inc.

101 Munson St., Suite 201
Greenfield, MA 01301

(413) 773-5555

Web: http://LifePathMA.org

Areas served: Ashfield, Athol, Bernardston, Buckland, Charlemont, Colrain, Conway, Deerfield, Erving, Gill, Greenfield, Hawley, Heath, Leverett, Leyden, Monroe, Montague, New Salem, Northfield, Orange, Petersham, Phillipston, Rowe, Royalston, Shelburne, Shelburne Falls, Shutesbury, Sunderland, Turner Falls, Warwick, Wendell, Whately

16. Minuteman Senior Services

One Burlington Woods, Suite 101
Burlington, MA 01803

(781) 272-7177

Web: http://www.minutemansenior.org

Areas served: Acton, Arlington, Bedford, Boxborough, Burlington, Carlisle, Concord, Harvard, Lexington, Lincoln, Littleton, Maynard, Stow, Wilmington, Winchester, Woburn

17. Mystic Valley Elder Services, Inc.

300 Commercial Street, Suite #19
Malden, MA 02148

(781) 324-7705

Web: http://www.mves.org

Areas served: Chelsea, Everett, Malden, Medford, Melrose, North Reading, Reading, Revere, Stoneham, Wakefield, Winthrop

18. Old Colony Elder Services, Inc.

144 Main St.
Brockton, MA 02301

(508) 584-1561

Web: https://www.ocesma.org

Areas served: Abington, Avon, Bridgewater, Brockton, Carver, Duxbury, East Bridgewater, Easton, Halifax, Hanover, Hanson, Kingston, Lakeville, Marshfield, Middleborough, Pembroke, Plymouth, Plympton, Rockland, Stoughton, Wareham, West Bridgewater, Whitman

19. SeniorCare, Inc.

49 Blackburn Center
Gloucester, MA 01930

(978) 281-1750

Web: https://seniorcareinc.org

Areas served: Beverly, Essex, Gloucester, Hamilton, Ipswich, Manchester-by-the-Sea, Rockport, Topsfield, Wenham

20. Somerville/Cambridge Elder Services, Inc.

61 Medford Street
Somerville, MA 02143

(617)628-2601

Web: https://eldercare.org

Areas served: Cambridge, Somerville

21. South Shore Elder Services, Inc.

350 Granite Street, Suite 2303
Braintree, MA 02184

(781) 848-3910

Web: http://www.sselder.org

Areas served: Braintree, Cohasset, Hingham, Holbrook, Hull, Milton, Norwell, Quincy, Randolph, Scituate, Weymouth

22. Springwell, Inc.

307 Waverley Oaks Rd, Suite 205
Waltham, MA 02452

(617) 926-4100

Web: http://www.springwell.com

Areas served: Ashland, Belmont, Brookline, Chestnut Hill, Dover, Framingham, Holliston, Hopkinton, Hudson, Marlborough, Natick, Needham, Newton, Northborough, Sherborn, Southborough, Sudbury, Waltham, Watertown, Wayland, Wellesley, Westborough, Weston,

23. Tri-Valley, Inc.

10 Mill Street
Dudley, MA 01571

(508) 949-6640

Web: http://www.trivalleyinc.org

Areas served: Bellingham, Blackstone, Brookfield, Charlton, Douglas, Dudley, East Brookfield, Franklin, Hopedale, Medway, Mendon, Milford, Millville, North Brookfield, Northbridge, Oxford, Southbridge, Spencer, Sturbridge, Sutton, Upton, Uxbridge, Warren, Webster, West Brookfield

24. WestMass Elder Care, Inc.

4 Valley Mill Rd
Holyoke, MA 01040

(413) 538-9020

Web: http://www.wmeldercare.org

Areas served: Belchertown, Chicopee, Granby, Holyoke, Ludlow, South Hadley, Ware

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Find Your Regional Aging Services Access Point (ASAP)

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Contact your ASAP to connect with services that can help you or your loved one age in the community.

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Access Care Partners

Primarily based in Western Massachusetts, help individuals >65 years and olders who require assistance to maintain their independence

Programs & Services:

Adult Family Care

Benefits Counseling Assistance

Community Resources

Family Caregiver Support

Home Care

Housing Services

InnerWell Behavioral Health

LGBTQ+ Support

Integrated Care Services

Money Management Program

Nutrition Services

Ombudsman Program

Personal Care Management

Transitions of Care

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Integrated Care Services - Access Care Partners

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Programs & Services Integrated CareServices At Access Care Partners, we’re dedicated to partnering with healthcare providers to become an integral part of our consumers’ primary care teams. Our mission is to ensure older adults and individuals with disabilities in the community feel supported, empowered, and safe while maintaining their independence. Whether you are part of […]

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UMass Memorial Health is an innovative home visit model in Central Massachusetts to help address medical concerns through use of paramedics.

Steps

1. Activation: initiate a mobile integrated health visit (FUN FACT: inpatient care teams can request this! upon discharge)

2. Dispatch: EMS sends paramedic to your home

3. Evaluation: paramedics will do full subjective history and physical exam

4. Physician Consultation: paramedics connect with physician via telehealth to discuss personalized treatment plan

5. Treatment vs Transport: based on physician plan, paramedics will deliver any basic therapies in home or transport patient to ED if needed.

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Our mobile integrated health service provides home visits from specially trained paramedics to patients with severe and chronic conditions.

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MGB Mobile Medical Community Care Vans: staffed with multilingual and multicultural clinicians and support staff to connect with communities served by MGB.

They currently provide the following services:

Hypertension and diabetes care

Substance use disorder

Social risk mitigation

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Our Community Care Vans are designed to expand access to health care services across the diverse communities in the Greater Boston area served by Mass General Brigham.

Mass General Brigham's mobile medical Community Care Vans bring a broad menu of mobile medical services, including screenings and interventions for chronic health issues like hypertension, diabetes, and substance use disorders. The Community Care Vans, originally deployed during the height of the COVID-19 pandemic, are staffed with multilingual and multicultural clinicians and support staff to better connect with the communities served by Mass General Brigham.

In January of 2021, Mass General Brigham launched a fleet of Community Care Vans in our local communities hit hardest by the COVID-19 pandemic, providing COVID testing, vaccines, and reliable health information to patients and residents. Information and resources were provided in a variety of languages along with care kits containing items like masks and hand sanitizer.

As of May 2023, the Community Care Vans had administered more than 20,000 vaccines to community residents. To address social determinants of health, patients are screened for issues related to housing, access to healthy food, and personal safety, and connected with relevant resources.

Now, as COVID-19 transitions from an acute pandemic to a more endemic state, the Mass General Brigham mobile medical Community Care Vans have also evolved to meet people where they are and currently provide the following services:

Hypertension and diabetes care: Screening and intervention, including blood pressure readings, lipid and A1C levels testing and physical activity assessments, titration of medication and connection to primary care medical homes

Substance use disorder: Screening, treatment program referrals and recovery coaching

Social risk mitigation: Ongoing assessments on social determinants of health (food, housing, etc.) with connection to services

Mass General Brigham Community Health leadership team with leaders from community partner La Colaborativa, as well as Congresswoman Ayanna Pressley.

1. Community Care Van 7

2. Community Care Van 1

3. Community Care Van 2

4. Community Care Van 3

5. Community Care Van 4

6. Community Care Van 5

7. Community Care Van 6

In your community

Our mobile van schedule is updated weekly. Find out information for dates, times, and locations.

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Community Care Van | Mass General Brigham

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Our Mobile Medical Community Care Vans are designed to expand access to health care services across the diverse communities in the Greater Boston area.

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Hero Medication Dispenser

Smart medication dispenser that is programmed to release specific medications at different times throughout the day. Uses an app to setup your medication schedule. Can load up to a 90 day supply of your meds.

AARP members get discount on subscription

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The Cost of Care

By improving your medication management, a Hero membership may help you avoid the far steeper costs of medication non-adherence, such as hospitalizations or frequent doctor's visits.

In some cases, Hero can also allow you or a loved one to avoid paying for in-home care or assisted living facilities, both of which cost thousands of dollars per month.

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Automatic Pill Dispenser & Medication Manager | Hero

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The Cost of Care By improving your medication management, a Hero membership may help you avoid the far steeper costs of medication non-adherence, such as hospitalizations or frequent doctor's visits. In some cases, Hero can also allow you or a loved one to avoid paying for in-home care or assisted living facilities, both of which cost thousands of dollars per month.

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Massachusetts Healthy Aging Collaborative 

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Massachusetts Healthy Aging Collaborative 

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Resource to stay up to date with new state guidelines related to the aging adult.

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Home - Massachusetts Healthy Aging Collaborative

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ReiMAgining Aging 2030: The Massachusetts Plan

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ReiMAgining Aging 2030: The Massachusetts Plan

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Important to stay up to date with state legislature plans. This one in particular focuses on making sure older adults

1. meet basic needs for living

2. make empowered decisions and meaningful relationships

3. enhance mobility and livability

4. optimize health

5. local and regional policies working towards similar goals

6. accessible information

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Key Messaging - ReiMAgine Aging 2030: The Massachusetts Plan

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Topline messages to keep in mind when promoting ReiMAgine Aging 2030: The Massachusetts Plan

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With higher percentage of depression and anxiety in older adults, this website has database to support different aspects and connect older adult to the appropriate support group

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This organization works to provide resources and assistance to older adults to help manage financial challenges related to aging. Resources range from health and wellness to job training to help filling out tax forms.

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Get support services in your area for housing, health, food, employment, and much more.

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Best Practices For Medication Management

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Best Practices For Medication Management

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According to Burton Korer, PhD(c), DNP, MSN, RN-BC, CPHQ, CADDCT, suggests that best practices include

1. Promote e-prescribing

2. Require cancel Rx orders for all medication changes and discontinuations

3. Enforce strict policies for transcribing and and reconciling all eMAR entries to the original prescriptions.

4. Discourage using a “shared” document, requiring prescriptions separate from the community physician orders and recaps.

5. Reconsider 28-day and multidose compliance packaging in high-acuity populations.

6. Maintain competencies for eMAR users in assisted living communities to maximize benefits from the software while also reducing errors and omissions.

7. Promote use by the assisted living community of oversight and surveillance reports on medication administration available in eMAR software.

8. Set guidelines, roles, and responsibilities for the assisted living community and pharmacy to manage “profile only” orders.

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Group Adult Foster Care (GAFC)

GAFC provides financial support for older adults through MassHealth.

Contact: MassHealth Customer Service Line

Number: 1-800-841-2900

Supplemental Security Income- Category G

Administered through the Social Security Administration

Find a list of SSA offices, to help determine if you qualify for assistance www.socialsecurity.gov/otherssasites.

Veterans’ Administration Aid and Attendance Benefit

VA Aid and Attendance Benefits may be available for Veterans and/or surviving spouses. For more information on this benefit, contact the Boston Regional Benefit Office at 1- 800-827-1000.