Elderly with complex health and social needs often do not receive the right medical and social services because of poor service integration and inadequate access to care. Integrating care is complicated, however, and requires a high degree of cooperation among organizations and service providers across different fields.
The ministries of Social Affairs and Health, Israel’s Social Security Administration, the national health plans, and JDC-Eshel are cooperatively developing a national model of integrated care using professional case manager teams. These teams include nurses and social workers who work together with the elderly and their families, in order to put together the best service package for each individual.
MJB’s 3-year evaluation of the implementation of the model is examining how integrated care can best help the elderly and their families.
Phase 1 of the evaluation focused on a pilot test in Ashkelon in 2015. Two of the important contributions were to better define the role of the case managers so they can work more effectively with the clients, and to identify the services that are most needed by the elderly and their families.
Phase 2 of the pilot that incorporated the lessons from the first phase, is now underway in four communities (Ashkelon, Jerusalem, Sdot Negev, and Netivot). This phase of the evaluation has two main goals:
- To assess the improved model of integrated care as a basis for its national adoption
- To measure the program’s contribution to the elderly, their families and the system of care
MJB’s study is supported by a special grant from Nancy Hackerman of Baltimore, USA.