Ypsilanti Meals on Wheels Uses Closed-Loop Referrals to Better Serve Aging Adults

America is experiencing unprecedented growth in its senior population that is on track to outpace resources currently available to vulnerable older adults. According to the Urban Institute, the number of Americans aged 65 and older will more than double over the next 20 years, reaching 80 million in 2040. The number of adults aged 85 and older, the group most often needing help with basic personal care, will nearly quadruple in that same timeframe.

It’s also known that the majority (80%) of older Americans have a desire to “age in place” rather than in institutions such as nursing homes. In order to grant most Americans’ wish without risking their health and well-being, there must be accommodating service arrangements and living environments conducive to safe, independent living.

Meals on Wheels is an established public-private partnership that effectively addresses the challenges of aging by promoting health and improving quality of life for at-risk seniors. By leveraging the existing Meals on Wheels network, communities around the country have the opportunity to not only keep seniors healthy and independent at home, where they want to be, but also save billions in tax dollars by keeping them out of more costly health care alternatives, according to Meals on Wheels America.

Since 1973, the Ypsilanti Meals on Wheels (YMOW) chapter located in Washtenaw County, Michigan, has provided nutritious meals, social contact, and other services to local homebound elderly, ill, and disabled senior citizens. The nonprofit is committed to helping aging adults lead healthier, safer, and more independent lives. It accomplishes those goals through its reputable home-delivered meal program, but what many may not know is that Meals on Wheels provides a long list of free long-term and short-term support services to participants, such as occupational therapy (OT), home modification services, nursing social work, pet food delivery, and even laundry services, in addition to meal assistance. Its robust network of services is the foundation to helping Ypsilanti residents truly “age in place” as safely and as comfortably as possible.

More Than Home-Delivered Meals

In Ypsilanti, a Meals on Wheels participant can receive meal support along with a long list of life-improving supplementary services. For example, research shows that seniors with pets are 36% less likely to suffer from loneliness and have 21% fewer doctor visits than those without a furry companion, so YMOW maintains its own Pets Assisting the Lives of Seniors (PALS) program, that offers free delivery of pet food, cat litter, and other pet supplies to participants. In partnership with the Humane Society of Huron Valley and Meals on Wheels America’s We Love Pets program, YMOW delivers thousands of pounds of food, treats, and cat litter to dozens of YMOW clients’ pets each year. Supplies are delivered monthly to the clients’ doors. In addition to food and supplies, YMOW clients can access pet grooming and veterinary services, including nail trims and preventative care, for a small contribution.

Every Monday, produce is delivered to YMOW from Food Gatherers, a local organization that works to alleviate hunger. On average, Food Gatherers supplies YMOW with about 400 pounds of fresh produce, dairy, and grains each week. These donations are distributed to YMOW clients to help stock their pantries and supplement their diets beyond the food provided in their regular daily meal delivery.

Additionally, YMOW staff and social workers collaborate with students from the University of Michigan and Eastern Michigan University to see that every YMOW client receives a full assessment of their needs. Once that assessment is complete, YMOW can pair seniors with a wide range of services and resources, including caregiver support for referrals to support groups and in-home services to care for their family members; help to obtain benefits such as Medicare/Medicaid and food stamps; medication review; and creation of a friendly visit program to combat social isolation.

On top of these and other formal local partnerships, YMOW regularly connects its participants with critical resources such as dental care, house maintenance and repair, affordable or subsidized housing, tax and social security assistance, transportation, abuse and mental health hotlines, and so much more. 

Challenges

YMOW’s robust referral network benefits its participants greatly, but it raised several challenges for YMOW staff in the beginning. One common pain point for nonprofits that leverage large networks of service providers is hindered collaboration. Participants and social workers are constantly jumping through hoops to receive care. These barriers to receiving help can exacerbate already intense feelings. Participants must often restate their needs and retell their stories to each organization and sometimes multiple caseworkers at each agency. Different programs may require different intake forms or use disparate logic models. Unfortunately, doing this can be an emotional, tense, and critical time for those seeking help. Having multiple people to talk to and forms to fill out can often lead to participants not getting the care they need and slipping through the cracks. 

Another pain point is scattered internal communication between different organizations. While they are all working toward a similar goal, each entity typically has their own way of collecting, tracking, and storing participant information. This can lead to long lead times to complete otherwise urgent items such as wheelchair ramp installation or delay the start of in-home OT visits for a recently discharged individuals. It can also lead to an overlap in tasks that can drain already-strained resources. Streamlining efforts without a unified case management platform proved to be quite the undertaking for YMOW in the beginning. 

In the beginning, Kellie Childs and her team at YMOW sought out a tool that would enable consistency and efficiency of their efforts. Childs notes that another Customer Relationship Management (CRM) platform was their first solution to go to trial. However, after nearly a hundred hours of training and even hiring an onboarding contractor specifically to help them integrate it into the organization, Childs admits the software still wasn’t a good fit for her and her team. She notes that the other CRM platform was much more than they needed, and it was “way out of bounds” with what their nonprofit could put to use. From there, Childs and her team cut their losses and forged ahead in finding a better tool that would better fit their nonprofit’s unique set of needs. 

Minding the Gaps 

Many nonprofits partner with other organizations to provide participants with all the care they need. However, the referral process can be problematic because it is often unknown if the referred participant actually receives care from the organization. If they do receive care, there is usually no visibility into what is happening for that person. This can affect the overall experience for the person served. Social Solutions’ Closed-Loop Referrals platform allows organizations to share information while maintaining confidentiality. This enhances participants’ care by providing a holistic view of a person’s care across organizations. 

Furthermore, before deploying our case management software, Childs notes that most of YMOW’s reporting was conducted by pen and paper, which meant that YMOW staff had virtually zero visibility into patterns and trends in terms of community demographics, program participation, outcomes, and more. This limited the organization immensely and contributed to inconsistencies in its outreach, limited reporting to its stakeholders and funders, and poor communication with outside agencies and care providers. 

Solution

Unlike the CRM platform they attempted to work with before, Social Solutions’ case management software is designed specifically for public sector and nonprofit social service organizations. The case management software helps thousands of social good organizations worldwide reduce administrative burdens and track performance outcomes to meet the needs of the whole person in a way that results in more impact in the communities they serve.

One core element of the all-in-one case management platform is its Closed-Loop Referrals feature. Closed-Loop Referrals bring the network and relationships that YMOW has built into the digital space for convenience, expedience, and assurance. The feature allows the ability to view and build a network of area providers within the case management software. As a result, it’s easier to translate and build existing relationships and streamline program participants on a path to success. The Closed-Loop Referrals feature seamlessly connects people and families to multiple service organizations and allows insight into their progress across all services. This translates to fewer red tape and hurdles for participants and enhanced transparency for case workers. It also reduces the need for program participants to repeat their “story,” which can be traumatic. 

Closed-Loop Referrals can also be used by other organizations that don’t have a Social Solutions case management software license. This is unique to the industry and can be a game-changer for both the referring and referred organization. The ability for both organizations to work fluidly within the Social Solutions case management platform makes it easy to search for partners, refer, and collaborate to quickly connect participants with the services they need most. It simplifies care coordination by keeping care teams informed so they know when participants are receiving services and by delivering a holistic view of care. It also helps by managing multiple referrals at once while eliminating manual phone calls and emails. It builds connections with other nonprofit leaders in the community and lends visibility into tracking, progress, and care coordination, which allows organizations to report on community outcomes. 

Impact

As an extension to the all-in-one, intuitive case management software, the Closed-Loop Referrals features have created an abundance of efficiencies for Childs and her team at YMOW. Now, YMOW can see the impact it has in the community and can better map patterns and fuse connections that strengthen its program over time. These efficiencies are clearly demonstrated through YMOW’s work with a local Catholic Social Services group. For instance, when an older person is discharged from the hospital, many times they need special home modifications made in order to transfer safely and independently out of a monitored health care setting. This might look like having a grab bar installed in the bathroom or a ramp at the front door. Through its partnership with Catholic Social Services, YMOW can work together to determine exactly what resources are needed, where the funding will come from, and how logistics will be delegated. For example, on-staff OTs with YMOW can make their own home assessment recommendations using a form within the case management software and share that form, which includes all required specifications, through an application called Home for Life Designs. This process eliminates redundancies, tracks progress, and even adheres to compliance mandates, all while guaranteeing that the funding allotted to these home modifications is being used in the best way possible. 

Going Digital

YMOW has digitized many other processes using the comprehensive case management software. Childs reports the nonprofit has cut time spent on caseloads by up to 75% and notes that her team has more time to talk to clients and focus on their case work rather than filling out tedious forms. This is remarkably significant considering that each of YMOW’s staff members has about 140 case files at any time. 

Identifying Patterns 

The case management platform gave YMOW the ability to generate regular reports that track patterns and demographics and help staff understand why some clients weren’t utilizing certain services. The information from the reports was then used to help the team adapt where needed. Childs also notes that the case management software showed her team areas where they could do more by comparing dropout rates for certain programs and then comparing that to case notes to explain why some participants stopped using specific services. 

Complying with HIPAA 

Perhaps the best part about utilizing case management software and its Closed-Loop Referrals feature is the compliance and security factor. While all of this inter-organization communication is happening, the team at YMOW, its funders, its clients, and its stakeholders can all rest easy knowing that the communication happening within the case management software is secure and compliant with local and industry mandates, such as HIPAA. This is significant because, in the past, staff would have to physically drive and deliver sensitive files to different partner organizations due to a lack of access to secure document-sharing tools. This gives staff critical time to see more clients and create deeper connections. 

Ensuring Equity 

One of the first things Childs noticed once YMOW deployed the case management software was that the program wasn’t seeing the diversity of clients that reflects YMOW’s service population. Childs says they were able to recognize this discrepancy early and realize that its patterns of screening might have been contributing to that, unbeknownst to them. She adds that the robust and intuitive reporting features found in Social Solutions’ case management software made it blatant that there were areas to improve when it came to equitable delivery of services, which is a main priority for the nonprofit. 

Summary

Looking ahead, YMOW plans to leverage the reporting and referral capabilities within Social Solutions’ case management platform to provide better care to the area’s aging adults. This means using data to better adapt and respond to the changing needs of its clients and community. It also means using the case management platform to execute on new improvements to their programming. For example, in the future, YMOW will roll out an improved “Care on Wheels” program to clients, which aims to help seniors gain skills, strength, and confidence to live happier, safer lives in their own homes. These initiatives will be supported and enabled by Social Solutions’ case management software and its Closed-Loop Referrals platform, which will ultimately allow YMOW to serve more people and make a greater impact in its community.