Age Wise Learning Collaborative with Lifestyle Medical

About the Program

Category: Human Services (Best in Category)

Year: 2023

The San Bernardino County Department of Aging and Adult Services – Public Guardian (DAAS-PG) Age Wise Learning Collaborative with Lifestyle Medical was established in April 2021. The collaborative focuses on building an innovative and effective community partnership to improve depression care for older adults and reduce mental health disparities. This collaborative partnership improves access to care, patient engagement, patient experience and quality of care by bridging access to direct resources and services. The learning collaborative is dedicated to serving San Bernardino County adults aged 59 years and over with an array of professional service and resource offerings, including: • In-Home Behavioral Health Counseling, • Telehealth, • Access to licensed clinical therapists available by telephone 24 hours a day, seven days a week including holidays (Age Wise 24/7 Senior Hotline), • Full-Service Case Management, and • Assistance and referrals regarding: o Feelings of isolation, o Food insecurity, o Transportation, and o Peer and family advocacy. This learning collaborative resulted in patients making healthier lifestyle choices and an increase in patients’ levels of resiliency toward daily challenges as their depression is addressed. All patients entering the learning collaborative were screened with the Patient Health Questionnaire (PHQ-9) for depression; the average entry PHQ-9 score was 17, moderately severe depression. Engagement with patients was bi-monthly for three months and resulted in an average leaving PHQ-9 score of 12, a movement from moderately severe depression to moderate depression.