Service Navigation Program Helps Older Adults Age in Place—and It’s Free

Nearly half of older adults require assistance with daily activities in a given month, according to data. Research indicates that older adults face significant barriers due to siloed health care systems and community agencies, including limited information on where to find help, complex application processes, and financial constraints.

Implemented at the Dorothy Adler Geriatric Assessment Center, The Agency on Aging of South Central Connecticut’s (AOASCC’s) Service Navigator program addresses the complex needs of families living with dementia. An AOASCC Service Navigator can meet with the older adult or family in their home, at the doctor’s office, or via telephone to address daily living needs and connect people with community-based resources, all at no cost to individuals.

The Agency on Aging offers a range of services, including access to in-home care, Meals on Wheels, home-delivered groceries, transportation, medical chaperones, caregiver support groups, insurance counseling, assistance with accessing financial benefits, chronic disease self-management, geriatric care management, psychosocial support, health literacy training, volunteer opportunities, and Medicaid Home and Community Based Services enrollment assistance.

“It’s a one-stop shopping approach,” says Richard Marottoli, MD, MPH, professor of medicine (geriatrics), medical director of the Adler Center, and project director of COACH, which supports this work. “There are many different agencies and services available, but the key with this program is having an experienced professional connect you with the right services in your location for which you’re eligible.”

Studies highlight that "navigation problems" are systemic, resulting in 1 in 2 older adults living alone struggling to afford basic needs. Help navigating services is most needed in health care coordination, home and community-based services, and caregiver support, research shows.

“When people need to navigate too many steps alone, they’re more likely to end up with unmet needs,” says Marottoli. “Patients and families find it invaluable for someone to guide them through the process because accessing services is difficult.”

For example, the Connecticut Home Care Program for Elders provides in-home support to older adults so they can remain safe in the community. However, it has a complex application and enrollment process.

“We’ve come across individuals who have applied two or three times in the past—and they’ve needed these services for years—but they haven’t been able to follow through with the required documentation,” says Mollie Gadarowski, Director of Clinical Partnerships at AOASCC. “We’ve been able to help gather documents, send them in, and connect them to services.”

Since its inception in 2022, the program has served over 1,000 older adults, people with disabilities, and caregivers in Connecticut.

“We're able to touch individuals we were unable to reach before,” says Gadarowski. “We have a high rate of success in helping people access needed services.”

Now, COACH and AOASCC are expanding the Service Navigation model into a primary care setting. The pilot is happening at Fair Haven Community Health Center, a federally qualified health center deeply rooted in the community. The center cares for many older patients and supports families who provide care for older relatives.

“The program has more than lived up to everything we hoped for,” says Marottoli. “It has shown us new ways these services can be applied that are extremely valuable to patients and families.”

To learn more about Service Navigation in Connecticut and to access services, visit AOASCC’s site or call a service navigator at 203-785-8533.