SOWK 432 Week 2 Community Resources Assignment Example

Community Resources Project: The Continuum of Care for Older Adults in a Virginia County, How Each Service Is Paid For and What Its Churches Add

Introduction

McInnis-Dittrich (2014) emphasizes that older adults' needs range from occasional help with errands to round-the-clock care, and that social workers must know the full range of services available to match each person to the least restrictive setting that keeps them safe. That range is often called the continuum of care. This project describes nine resources for older adults in Danforth County, a composite rural county of about sixty thousand residents in Virginia's Piedmont, arranged from community services that help people stay at home to care at the end of life. For each, it defines the service, explains whom it serves and identifies how it is paid for. A final section describes how local churches support older adults and their families.

Area Agency on Aging

The Piedmont Area Agency on Aging is the county's front door for aging services. It provides information and referral, benefits counseling and case management, helping older adults and families find and apply for the programs described below. Its funding comes largely from the Older Americans Act (1965), supplemented by state general funds and county contributions. Its services are free to people aged 60 and older, though donations are invited.

Home-Delivered Meals

The agency's Meals on Wheels program delivers a hot noon meal five days a week to homebound adults aged 60 and older, along with frozen meals for weekends. Beyond nutrition, the daily visit gives isolated residents human contact and a quick wellness check. Meals are funded through the Older Americans Act nutrition program, with state funds and voluntary contributions, and inability to pay never disqualifies anyone.

Family Caregiver Support Program

Relatives deliver the largest share of the help older people get at home. The agency's caregiver program offers counseling, support groups, training and short periods of respite care, giving caregivers time to rest. It is funded through the National Family Caregiver Support Program under the Older Americans Act, with some cost sharing based on income.

Adult Day Health Care

Danforth Adult Day Center offers supervised activities, meals, medication help and nursing oversight on weekdays for older adults with physical or cognitive impairments, allowing family caregivers to keep working. Families usually pay a daily fee; eligible participants may be covered through Virginia's Medicaid home and community-based services waiver, and some veterans receive coverage through the Department of Veterans Affairs.

Medicare Home Health

Two certified home health agencies provide skilled nursing, physical therapy and related services to homebound older adults recovering from illness or surgery. Medicare covers intermittent skilled home health care for beneficiaries who are homebound and under a physician's plan of care, with no copayment for the home health services themselves (Centers for Medicare & Medicaid Services [CMS], 2024). Medicaid covers some home health services for eligible low-income residents.

PACE

The regional PACE center enrolls residents aged 55 and older who meet the state's nursing home eligibility standard yet are judged able to remain safely at home when they join. PACE combines primary care, day center services, therapy, transportation and home care under one team. It is funded mainly through Medicare and Medicaid; people who qualify for both usually pay nothing, while others may pay a monthly premium (CMS, 2024).

Assisted Living

Three assisted living communities in the county provide housing, meals, help with personal care and medication management for people who can no longer live alone but do not need skilled nursing. Most residents pay privately. Medicare does not cover assisted living, and Virginia's Medicaid coverage for assisted living is limited, so cost is a major barrier for low- and middle-income families.

Skilled Nursing and Long-Term Nursing Home Care

Danforth Health and Rehabilitation provides both short-term rehabilitation and long-term care. Medicare pays for skilled nursing facility care for as many as 100 days per benefit period following a hospital admission of three or more days as an inpatient, with a daily coinsurance beginning on day 21 (CMS, 2024). Medicare does not cover long-term custodial care. Most long-term residents rely on Medicaid once their savings are spent, while others pay privately or through long-term care insurance.

Hospice

Blue Ridge Hospice offers comfort care to terminally ill residents, usually at home, along with support for families and bereavement services afterward. The Medicare hospice benefit covers this care for beneficiaries whose physician certifies a life expectancy of six months or fewer, assuming the disease follows its expected course (CMS, 2024). Medicaid and many private insurers also cover hospice.

How Local Churches Aid Older Adults

Danforth County's congregations fill gaps that public programs leave. Mount Olive Baptist Church coordinates a volunteer driver ministry in which about thirty church members take older adults to medical appointments, the pharmacy and the grocery store, a vital service in a county with no public transit. St. Luke's Methodist Church employs a part-time parish nurse who checks blood pressure after Sunday services, visits homebound members and helps families understand discharge instructions and medications. Grace Lutheran Church hosts a monthly respite day, staffed by trained volunteers, where caregivers can leave a loved one with mild dementia for five hours of music, crafts and lunch.

Research suggests that the relationships churches offer matter as much as the services: Krause (2006) found that older adults who received more emotional support from fellow church members had lower mortality over the course of his study. Social workers can strengthen these ministries by connecting them with the Area Agency on Aging, so that the driver ministry receives referrals and the respite day can serve caregivers from the agency's support groups. The churches, in turn, can help the agency reach isolated older adults who will not call a government office but will open the door to someone from their congregation. In the future, the ministerial association could organize a shared volunteer pool and a calendar so that no older adult waits weeks for a ride to a specialist.

Gaps and Recommendations

The largest gaps in Danforth County are transportation outside church networks, affordable assisted living and respite for caregivers of people with advanced dementia. A social worker could advocate for county funding of a demand-response van service and encourage additional congregations to host respite days.

Conclusion

Danforth County offers a real continuum of care, from meals and caregiver support to PACE, nursing homes and hospice, funded by a mix of the Older Americans Act, Medicare, Medicaid, state and local funds and private payment. Its churches add transportation, health monitoring and respite that public programs cannot fully provide. In Proverbs 16:31, white hair is a crown of splendor when found on the path of righteousness (English Standard Version Bible, 2001/2016), and a community that knows its resources and connects its congregations with its agencies can help older adults wear that crown at home as long as possible.

References

Centers for Medicare & Medicaid Services. (2024). Medicare & you 2025: The official U.S. government Medicare handbook. U.S. Department of Health and Human Services.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Krause, N. (2006). Church-based social support and mortality. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 61(3), S140-S146. https://doi.org/10.1093/geronb/61.3.S140

McInnis-Dittrich, K. (2014). Social work with older adults: A biopsychosocial approach to assessment and intervention (4th ed.). Pearson.

Older Americans Act of 1965, 42 U.S.C. § 3001 et seq. (1965).