Jonathan Reckford of Habitat for Humanity International

Leaders from Habitat for Humanity and other housing and senior advocates are calling for approaches that better integrate health and social services delivered at home, a need they say has been indelibly underlined by the COVID-19 pandemic.

Habitat launched one such program, CAPABLE, in 2018. It pairs RNs and occupational therapists with clients who receive in-home care including assessments of environmental changes that could improve health outcomes. Repairs that support individual goals are then completed by Habitat.

Similar holistic programs could pair home health workers with other social service organizations to identify needs such as home improvements, utility assistance or access to food. Hospitals and community groups must work together to integrate such efforts, said Jonathan Reckford, CEO Habitat for Humanity International, during an hour-long YouTube conversation Wednesday.

“There may be an expansion of these because everybody understands at this point that we don’t have a system of care where everything fits together,” added John Feather, Ph.D., CEO of Grantmakers In Aging. 

Geriatric Nurse Practitioner Alice Bonner, director of strategic partnerships for CAPABLE and an adjunct faculty member at Johns Hopkins University School of Nursing, said identifying needs should be a two-way street. While home health workers could refer non-health needs to social organizations or government agencies, community organizations may also be able to identify a need for skilled care if properly trained.

She advises CAPABLE, designed by Johns Hopkins, which has been implemented around Denver, in the Twin Cities, in Philadelphia and parts of Maryland. The program is based on the idea that disabilities in older adults result from a combination of medical and environmental factors. Bonner said the program’s multi-disciplined approach should be recognized as one that can help carry vulnerable populations through normal times, as well as through this pandemic or the next local or natural crises.

Funding remains an issue.

Aging receives just 2% of all philanthropic support in the U.S., according to Feather. He said senior care and housing organizations need to work with healthcare providers to develop partnerships and funding relationships that can further successful aging-in-place strategies.

Earlier this week, Independence Blue Cross launched a similar program in the Philadelphia region, promising to coordinate healthcare and tackle social factors that determine quality of life.