1. SHARP DOWNTOWN SENIOR SERVICES

2. Community Needs Assessment Integrated Services – Physical health – Mental health – Psychosocial services – Socialization

3. Challenge Separate funding streams Appeal to city/county Separate organizations

4. SOLUTION COORDINATED CARE: (a virtual “PACE-like” Program)

5. INTEGRATED CORE SERVICES Physical Health Social Work & Social Services Mental Health THE CLIENT

6. ORGANIZATIONS INVOLVED

7. 48 years serving the San Diego Community $$___ in under & uncompensated care to San Diego Residents in 1999 Leading Provider of HealthCare in San Diego Recognized Nationwide for Competencies in Numerous Medical Specialties Originator of Sharp Senior Health Center Comprehensive Senior Care Model Commended by JCAHO 1997 & 2000 for Sharp Senior Health Center SHARP Memorial Hospital

8. SHARP Mesa Vista Hospital Leading Provider of Inpatient, Outpatient Adolescent and Adult Mental Health Services in San Diego County Six years of Coordinated Care Delivery with Senior Community Centers PET Team HOT Team Member Dedicated Geriatric Psychiatry Program

9. Senior Community Centers 25 years serving seniors in San Diego Daily Meals Provided to Approximately 1,000 seniors Leading Provider of Senior Nutrition and Psycho-Social services in the County Innovator in Low-income Senior Housing

10. FUNDING SOURCES SMH Medicare Medi-Cal Grants Private Donations CDBG Capital $$ SCC SD County Grants Private Donations SMV Medicare Medi-Cal Grants Private Donations

11. PHYSICAL HEALTH SERVICES Primary Care Podiatry Nutrition Assessment Pharmacy Assessment Health Education Coordinated Ancillary/Specialty Care

12.  Medication Assistance Program  RN Case Management  Health Screenings  Insurance/Billing Assistance  Medical Social Work

13. MENTAL HEALTH SERVICES  Psychiatric Consultation  SRO Manager/Resident Outreach  Mental Health Education  PET Team  Inpatient/Outpatient Care  Outreach Case Management

14. PSYCHO-SOCIAL SERVICES Socialization Nutrition Social Services Harm Reduction Home Delivered Meals Case Management Residential Living

15. Case Study Mr C. 63 yo wm Dx: Multiple medical problems – Hx stroke, MI, – DM – HTN – Hypercholesterolemia – Nocturia, incontinence

16. Mr. C (continued) Social issues – MediCal eligibility problems – Housing – Boredom – Lack of self esteem

17. Mr. C (continued) Psych issues – Referred pt to Cross Cultural Grant Program (through Mesa Vista- pts seen at SCC)