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    Lights, Camera, Aging: A Local Companion to Aging Our Way, PA

    Domain 7: Health Services and Community Supports

    Health Services and Community Supports Tactic Profiles

    Like people of every age, all older adults rely on their communities for help at some point or another. This domain examines whether community and health care is available, accessible, and affordable.

    Aging Our Way, PA Tactic 131:

    Establish at least one dedicated navigator in every Area Agency on Aging (AAA) who is equipped with standardized training in case management, information and referral tools, customer service, and resources related to health care services and community supports, housing, social engagement and transportation.

    Overview:

    Note: This tactic profile was developed in collaboration with the Department of Corrections, and focuses significantly on the re-entry process.

    Like all of us, older adults need sources of information that are easy to understand from sources that they can trust, especially when navigating complex challenges like housing insecurity, re-entry following incarceration, and behavioral health issues. Many AAAs fill this role already by working with the Department of Aging (PDA), the Department of Corrections (DOC), local Veterans’ Affairs offices (VAs), and others to support older adults in such times of vulnerability. Having a dedicated AAA staffperson who can assist individuals, families, and caregivers in navigating the social service system, as well as improving the network of navigation support for that staffperson, would improve access to needed resources, referrals and assistance.

    Recommended Localized Tactics:

    • Train staff at AAAs and other social service organizations in the use of the Transition from Jail to Community Toolkit, the Faith-Based Organization (FBO) Re-Entry Partnership, and other re-entry support resources (see “Resources” section below).
    • Consult with officers in the V.A. to ensure robust support for older veterans with complex cases, and adapt V.A. processes to support civilian populations with similar needs.
    • Improve communication and network ties between state agency partners, non-profit organizations, prison social workers, parole officers, volunteer mentors, and other re-entry partners.

    Key Players and Partners:

    • State agencies: PDA, DOC, DMVA, DHS
    • Local social services: AAAs, County Assistance Offices, County Health Departments, VAs, Housing Authority, Careerlink, FBOs, non-profit organizations
    • Prison system: State Correctional Institutions (SCIs), County Prisons, Parole Offices
    • Healthcare: physical and behavioral health providers, long-term care facilities

    Resources:

    Examples:

    • Foundation of Hope is an interfaith FBO in Allegheny County focused on supporting incarcerated people and returning citizens of all ages throughout the re-entry process.  Their comprehensive support process has a proven track record of success, and could support similar models across the state. 

    PA Council on Aging Contact:

    Beth Herold, Bherold@co.butler.pa.us

    Charlotte McDaniel, charlotte.mcdaniel@gmail.com

    Carrie Nelson, cnelson@westmorelandcountypa.gov

    Aging Our Way, PA Tactic 145:

    Develop and build upon activities and mechanisms for older adults, families, and communities to plan and prepare for individual and public emergencies, especially those who live in nursing homes, are homebound, or belong to historically marginalized communities.

    Overview:

    The PA Emergency Management Agency (PEMA) coordinates with federal, state, local, and non-governmental partners to connect County emergency managers with resources on emergency planning, hazard mitigation, emergency response, and disaster recovery.

    To proactively plan for emergency situations, local governments should review results of community assessments to identify locations of vulnerable older adults and people with disabilities. Local emergency management coordinators and relevant staff/volunteers should be educated on the lived experience of older adults, especially those with high social vulnerability and/or from historically marginalized communities.

    Recommended Localized Tactics:

    • Identify and connect with Voluntary Organizations Active in Disaster (VOAD) coalition members in your area and engage them in supporting older adults.
    • Recognize and plan for special needs during an emergency including chronic diseases, functional limitations, mental health support, evacuation transportation, location of adequate special needs shelters, and availability of effective communication in multiple languages. Involve aging services providers, active adult centers, local libraries and provide information at health fairs.
    • Older adults affiliated with community agencies, housing communities, and health care facilities should become aware of their emergency preparedness plans. Senior facilities should be encouraged to review their current policies, conduct drills, and revise plans as needed.
    • Area Agencies on Aging, healthcare, and rehab/senior housing providers could boost use of emergency preparedness resources during intake and discharge planning.
    • Social media toolkits are available to assist with emergency management education for residents and organizations.

    Key Players and Partners:

    • PA Department of Aging/Local Area Agencies on Aging
    • PA Department of Human Services for assistance with public benefits such as SNAP and replacement benefit cards
    • National Voluntary Organizations Active in Disaster is an association of organizations that mitigate and alleviate the impact of disasters, provides a forum promoting cooperation, communication, coordination and collaboration; and fosters more effective delivery of services to communities affected by disaster. Organizations include Red Cross, Team Rubicon, and faith-based associations. PA VOAD is the chapter for the Commonwealth.

    Resources:

    Examples:

    • PEMA has resources for community discussions titled Preparing Together at Ready PA. These discussions create a community network to increase readiness for disaster response and recovery. 
    • St. Louis Crises Response - The collaborative response to the displacement of over 160 Heritage House residents in 2024 due to flooding caused by water pipes bursting.
       Arizona Emergency Information Network adopted the Ready, Set, Go! Program that encourages proactive measures to take before and after an emergency.
    • Allegheny, Bucks, Monroe, and Wyoming Counties have strong emergency programs.

    PA Council on Aging Contact:

    Linda Doman, ljdoman@comcast.net

    Aging Our Way, PA Tactic 129:

    Expand existing opportunities for education, training, and case management for caregivers.

    Overview:

    Caregiving can be both rewarding and overwhelming. Many times, loved ones find themselves starting their caregiver journey suddenly due to a health emergency.  Families are not as large or tight-knit as previous generations, and children may live out of state and not be available to help. 

    Paid and unpaid caregivers need more support. Resources to help with unpaid caregiving must be available to all Pennsylvanians to ensure they have all the tools to assist with providing their loved one with care and taking care of themselves.  Additionally, opportunities for education and training need to be expanded for paid caregivers in the direct care workforce.

    Recommended Localized Tactics:

    • Encourage all hospital discharge planners, skilled nursing facilities and home health agencies to provide the PACareKit information to patients.  Educate physicians and staff on the PACareKit.
    • Gather, verify, and disseminate information on state and local resources to support unpaid caregivers, distributing on websites, via social media, and through printed materials shared at community events and sent through the mail.
    • Work with local high schools, colleges/universities, and technical schools to establish or expand training programs for CNAs, direct support professionals, and home health aides, and build connections with community foundations and other funders to provide scholarships for the programs.

    Key Players and Partners:

    • Social Workers at hospitals, skilled nursing facilities and home health agencies.
    • Healthcare Professionals and auxiliary staff
    • Chamber of Commerce, Civic Clubs, Veterans Groups
    • Churches and Faith based groups, bulletins and newletters
    • Post Offices – Posters with tear off cards
    • Grocery Stores – Grocery bag stuffers
    • American Legions/VFW’s – Education, cards
    • Senior Centers – Education, cards
    • State Legislators

    Resources:

    • PACareKit is a collection of tools, information, and support to help you learn more, plan ahead, or catch your breath. It’s here to support your role, your time, and your needs – because caregiving rarely comes with instructions.
    • The Department of Aging administers the Caregiver Support Program through the AAAs as one of the federally-funded core services required by the Older Americans Act.

    Examples:

    PA Council on Aging Contact:

    Jennifer Drake, jenniferd@udsfoundation.org

    Aging Our Way, PA Tactic 6:

    Increase the availability and quality of comprehensive physical and mental health services, social engagement, and supportive accessibility adaptations for incarcerated older adults, including expanding older adult enrichment programming.

    Overview:

    In 2024, 12% (4,797) of inmates were age 60+ in PA state correctional institutions (SCIs).  Specialized services are needed for older inmates addressing mental health needs, memory disorders, enrichment programs, accessibility, and health care.

    PA state prisons can coordinate with local county prisons/wardens to assist older inmates needing additional treatment.  Area Agencies on Aging assist with local services available for inmates and families during incarceration and reentry.

     Local support from various community organizations will be helpful with offering and/or staffing programs in the prisons, provide support to families, and as volunteers through the AAAs current and developed programming. 

    Recommended Localized Tactics:

    • Connect with local county prison warden and board for status of older inmate programs and desired enhancements. 
    • Consider local implementation of Senior Life Enhancement Program (SLEP) program and digital programming.
    • Connect with Area Agency on Aging for status of support services and exploration of new opportunities and joint programming.
    • Prioritize family support throughout incarceration and reentry.

    Key Players and Partners:

    Resources:

    Examples:

    • SCI Laurel Highlands has hospice and palliative care available and can be a resource for other prisons. PA Department of Corrections has a compassionate release eligibility process.
    • SCI Huntingdon opened a Senior Life Enhancement Program (SLEP) in September 2025. SLEP offers a variety of enrichment activities. SLEP activities are offered several days per week and include arts, games, and socialization with peers. There are 12 SLEP programs statewide for inmates age 50+; more information is available from PA Department of Corrections.
    • Allegheny County Area Agency on Agency provides specific resources on its website for Allegheny In Jail and After Jail support.

    PA Council on Aging Contact:

    Linda Doman, ljdoman@comcast.net

    Aging Our Way, PA Tactic 19:

    Increase access to evidence-based resources and training related to detecting and reducing the risk of suicide in older adults.

    Overview:

    Older adult suicide continues to grow in disproportionate numbers across Pennsylvania, and the Commonwealth is beginning to take steps that specifically focus on this growing concern among the older adult population.

    There is a statewide suicide prevention plan, under OMHSAS (Office of Mental Health and Substance Abuse Services), but the plan does not focus on older adults specifically. The Pennsylvania Older Adult Suicide Prevention Work Group, as part of the Older Adult Committee for the Mental Health Planning Council, recently completed a 5-year study on this issue and has produced a “Pennsylvania Older Adult Suicide Prevention Work Plan”, which will be helpful in implementing ways to address this issue at the local and state levels through awareness, training, outreach, and safety planning.

    Local governments and their health and outreach partners can use the Work Plan and other resources in this Tactic Profile to improve preventative outcomes for at-risk older adults in their own communities.

    Recommended Localized Tactics:

    • Endorse the “Pennsylvania Older Adult Suicide Prevention Work Plan” from the Older Adult Committee of the Mental Health Planning Council to be adopted at the local and state levels for all groups working with older persons.
    • Utilize evidence-based training programs, such as the E4 Center training modules, for local first responders and statewide crisis programs to ensure standardized, evidence-based, unbiased mental health and suicide crisis responses for older adults.
    • Encourage the Aging Network and their partners to work with PDA and PA Department of Human Services (DHS) to identify and utilize evidence-based training for case managers and other staff within both the community and long-term care systems across the state.
    • Encourage the Aging Network and partners to offer community-based training for older adults, caregivers, and community members to raise awareness and support.
    • Work with county human services departments to develop cross-training between the aging network and healthcare providers, including mental health providers and crisis teams, to encourage integrated intervention procedures to improve crisis intervention outcomes for older adults.

    Key Players and Partners:

    • State Level – PA Department of Aging (PDA), Office of Mental Health and Substance Abuse (OMHSAS), Office of Long Term Living (OLTL), and other state departments responsible to serve older adults can also ensure coordinated, statewide training and strategies to promote outreach, education, and action among staff and providers.
    • County Level – Health, Human Service, and Aging departments at the County level can come together to coordinate efforts and support planning for older adult suicide prevention strategies and ensure inclusion in county-wide suicide prevention efforts and task force actions.
    • Local Community Task Forces – Emergency responders, local nonprofit and human service providers, health care systems, and long-term care providers can join local suicide prevention task force groups across PA to ensure the suicide prevention education and outreach is effectively reaching all who work with older adults in the community and effectively implementing trainings and outreach within the community in a coordinated way.

    Resources:

    • Pennsylvania Older Adult Suicide Prevention Work Plan - a five-year study with recommendations from the PA Older Adult Suicide Prevention Workgroup, part of the Mental Health Planning Council. This Work Plan raises awareness of suicide among older adults as a growing community health problem, and outlines actions to address this issue and deter onset or reduce the incidence of risk. Co-chairs of this group are Tony Salvatore (tsalvatore@mces.org) and Laurie Barnett Levine.
    • While the Work Plan is not currently available online, a digital copy can be obtained by emailing Joanne Kline at jkline414@hotmail.com.

    Examples:

    • The Older Adult Suicide Prevention Task Force, a committee of the Montco Suicide Prevention Task Force, is currently working within Montgomery County to raise awareness of older adult suicide risk and prevention among providers serving seniors in county. This committee has created detailed fact sheets to help in training, and plans are underway for screening, outreach and education aimed at prevention activities at all levels of care for older adults, including community/home care; assisted living; skilled nursing/rehab; CCRC’s, etc.
      Contact: Tony Salvatore, Montgomery County Emergency Services, tsalvatore@mces.org

    PA Council on Aging Contact:

    Joanne Kline, jkline414@hotmail.com

    Aging Our Way, PA Tactic 7:

    Review licensure requirements for skilled nursing facilities (SNF), Assisted Living Residences (ALRs), Personal Care Homes (PCHs), and administrators with respect to older adults with long term services and supports (LTSS) needs and behavioral health issues, including substance use disorder and those leaving the justice system, and modify policies and requirements to ensure facilities promote a culture of safety and reduce barriers for admission to facilities when needed and preferred.

    Overview:

    Approximately 27% of Pennsylvania's prison population is considered geriatric (aged 55+), a demographic that has grown by 300% since 2001, driving up medical costs and straining the system. This presents an opportunity for local municipalities to engage with Long-Term Care options in their communities to ensure safety and address barriers faced by older adults to access needed services.

    Pennsylvania Department of Health licenses Skilled Nursing Facilities (SNF).  Personal Care Homes (PCH) and Assisted Living Residences (ALR) are licensed by the PA Department of Human Services Office of Long-Term Living. Admission to SNF, PCH, and ALR is regulated by these entities.  There are barriers because of regulatory requirements surrounding older adults with specific health issues, financial abilities, and criminal backgrounds being admitted to a facility. 

    Recommended Localized Tactics:

    • Develop a relationship with the Long-Term Care options for your local area and provide information on admission criteria to assist residents in choosing a facility based on their health needs.
    • Support legislation to establish funding and regulatory changes to serve the changing medication needs of residents.
    • Review current facilities and closed facilities in your community that can be redeveloped to provide the programming needs of residents. 
    • Advocate for funding increases for PCH Supplement to increase the availability of housing options for low-income older adults.  Advocate for expanding Medicaid to ALR’s to provide this housing option for older adults that do not require a SNF.
    • Support requirements for education on non-pharmacological interventions, crisis prevention intervention and LECOM Bridges education related to understanding behavioral health.
    • Promote the PA211 as a resource for older adults for services.

    Key Players and Partners:

    Reach out to local or regional offices of the following for representatives:

    Resources:

    Examples:

    • Devereux Cares integrates the latest scientific and medical advancements with time-tested philosophies and compassionate family engagement to provide practical, effective and efficient care.
    • LeadingAge PA convened a task force of members from the Behavioral Health community that developed the concept of a HUB – a 6 full-time member team composed of RNs, Part-time Psychiatrist, Mental Health Counselor, and a Rehab professional.  The HUB is a space in a Long-Term Care facility that would be able to admit and treat complex cases with the goal of building capacity. The staff would be educated to provide expert care to the residents.  For information on the project, reach out directly to LeadingAge at info@leadingage.org.
    • Lancaster County Area Agency on Aging website for the AAA includes information on Long Term Care options and how to choose a facility. 
    • Tapestry Senior Living in Moon Township participates in Community Health Choices. In lieu of services, the program provides low-income older adults an alternative to a skilled Nursing Facility (SNF).

    PA Council on Aging Contact:

    Linda R. Stumpf, lrstumpf25@gmail.com

    Margie Zelenak, mazelenak@gmail.com

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