Institute on Aging (IOA): Multipurpose Senior Services Program (MSSP)

The Institute on Aging’s Multipurpose Senior Services Program (MSSP) provides long term care management services to low income seniors in San Francisco who are at risk for institutionalization or hospitalization.

Once referred to our program, the client receives a joint home visit from a nurse and a social worker who conduct health and psycho-social assessments.  A comprehensive care plan is created based on needs identified at the visit by both staff and the client.  Clients then receive at least monthly phone calls and quarterly home visits until their next annual reassessment, when the care plan is updated to reflect any changes.  Enrollments and assessments are presented at an interdisciplinary Care Plan Conference with nursing, social work, clinical supervisor, and psychology staff present.

Ongoing service coordination can include services such as: transportation, health care, homecare, home safety  modifications, legal assistance, home delivered meals, money management, day programs, therapeutic counseling, as  well as general advocacy and provision of information related to all services necessary to maintain quality of life in one’s own home  in the community.  MSSP is also able to purchase items for client that promote health and safety while reducing risk of institutionalization – such as basic household needs, home modifications, personal care items, medical equipment recommended by the doctor but not covered by insurance.  MSSP Care Managers coordinate all of the above while working collaboratively with the clients existing formal and informal support systems.

MSSP, a Medi-Cal Waiver Program, is available free of charge to all San Francisco residents aged 65 or older who are covered by Medi-Cal and who need assistance with at least two Activities of Daily Living.

Services are available in Spanish, Russian, Cantonese, Mandarin, and Farsi.  Translation is used for other needed languages.  Our program staff is very diverse and reflects the population of San Francisco.

Aging in place:  MSSP offers an alternative to institutionalization via long term, non-intensive care management that provides the resources needed to maintain a client’s safety at home. MSSP care management supports community living by fully assessing our clients’ needs, and then by monitoring chronic health conditions, coordinating medical care, ensuring adequate in-home support and equipment, purchasing needed services and items, and assisting clients and their caregivers and families with navigating the array of services available in their community.

Medically and psychologically frail, low-income elderly, age 65 and older.  Must have Medi-Cal.

Care management, coordination of services, supportive counseling, advocacy

The internship will be 2-3 days per week.

• After training and orientation, the intern will co-case manage at least 3 but no more than 8 cases.
• The intern will conduct monthly contacts with clients via telephone and home visits, as well as initial psychosocial assessments and annual reassessments. The intern will develop and revise comprehensive care plans based on a) the client needs identified during monthly and annual assessments and care plan reviews, and b) the input of the MSSP multidisciplinary team in weekly team care planning conference.
• The intern will identify, coordinate, facilitate, and/or purchase needed services for clients. The intern will provide clinical justification for all services rendered, including ongoing care management services.
• The intern will coordinate independently with clients’ social support systems, providers, and community resources to provide the clinically appropriate resources necessary to maintain clients safely in the community.
• The intern will document all efforts, interactions, and purchases expended on a given caseload according to requirements explicated in the CDA MSSP Site Manual as well as those requirements listed in the IOA MSSP Policies and Procedures Manual.
• The intern will receive weekly supervision from his/her Master’s-level field instructor
• There are many topics available for research projects if needed.
• The student is eligible to attend all workshops presented by the IOA free of charge and will be notified as community presentations are announced

See above

Any second language is helpful but not necessary.

coverage for travel expenses to visit clients

Name

Title

Phone Number

E-mail Address

Sara Dull Pacheo LCSW

Director, MSSP

415-750-8757

sdull@ioaging.org

Cesar Smith-Diaz

Senior Case Manager MSSP

415-750-8791

cdiaz@ioaging.org