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The African American Elders Program, run by Catholic Community Services, serve older B/AA who are home bound, hard to serve, low income, and have chronic and/or severe disabilities, living with dementia and related disorders, and are at high risk of premature institutionalization. The program specializes in providing culturally competent and sensitive care specific to B/AA that have lived in a high crime environment and with a lifetime battling discrimination and racism.

The Care Coordinators (CC's) are Master's-prepared Geriatric Social Workers who identify with the long-term effects of racism. They provide assistance to clients who have deficits of one activity of daily living (ADL) and/or two Instrumental (IADL's) deficits; and are unable to access services on their own; and do not have anyone to help them assess these services.

Care Coordination includes conducting a comprehensive assessment that focuses on cognitive and functional areas, evaluation of social circumstances, and resources. The assessment also includes medical diagnosis, nutritional concerns, emotional issues, medication management, safety, support, caregiver needs and continuous support with healthcare providers. This assessment leads to the development of a service plan and implementation. The care coordinators continue to follow-up and monitor the outcomes and status of the service plan for optimal outcomes and to amend service plans as needed.

Follow-up activities includes: home visits, telephone, and electronic communications with clients or their representatives.