Category: Neighborhood and Built Environment

13 - An Insidious Approach To Improve Safety, Comfort And Health Status Of Elderly Residents In A Rural Community

Importance Loss of caregivers to opioid addiction and disintegration of the nuclear family challenge rural communities to maintain safety, comfort and health status for their elderly populations.  Fragmented services, limited accessibility to needed services, lack of communication and cooperation among community entities contribute to ineffective or costly outcomes.  Communities lack the leadership and financial resources necessary to address these problems effectively.

Objective To explore whether a small community senior program can insidiously influence community practitioners and programs to exploit untapped resources through improving cooperation and coordination in order to improve health and social services.

Design, Setting, Participants This activity involved implementing a care management program and soliciting cooperation of several medical practitioners in a rural community. The senior center offers this as a service to the rural family practice offices.   Once high risk elderly seniors are identified, they are referred to the senior center where services such as education/support for chronic illnesses, meals on wheels, in-home personal care/assistance, transportation, legal aid, and access to a variety of socialization activities are made accessible.  This service is a central mechanism by which proactive monitoring of at risk elderly assures needed services are responsive and person-centered.  Clients are called by telephone weekly and needs addressed either through facilitated access to the medical practitioners office for an appointment (avoiding ER Use) or by reassuring and supportive interactions by care giving staff.    

Main Outcomes and Measures:  We have increased the number of proactive interactions with clients which has led to increase in care management and other services for the elderly.  This has led to a more intact system of care, open communication and more proactive care planning with local clinicians.  

Although still early in the process, we are seeing a greater number of senior residents and their caregivers utilizing our senior services more proactively.  We will monitor this program to evaluate our effectiveness in reducing unnecessary hospitalizations and/or improved follow up after hospitalization.  In addition, this activity provides extra incentive to local clinicians who now can receive credit for improving the quality in the Medicare merit-based incentive program (MIPS).

Conclusion and Relevance A small senior program in a rural community can insidiously promote system cooperation and coordination to tap resources and better meet the health and social needs of a rural elderly population. 


Mary Bliziotes

Senior Liaison
Senior Life Services of Morgan County
Berkeley Springs, West Virginia

Ms. Bliziotes is a public health professional dedicated to working with special populations. In 2017, she initiated a community project to impact positively on the lives of elderly residents in a small rural community in WV. Her work has been a slow, from the bottom up, approach that has led to an increase in the number of elderly accessing timely, appropriate community services that are person centered and help to keep people in their homes longer. The project is still young, but the reception of local health care providers and the elderly residents has been supportive. Ms. Bliziotes has over 40 years of experience working with disenfranchised populations through the Public Health Service, Charitable Care Clinics, and Community Health Centers.